International Emergency Nursing 31 (2017) 30–35

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International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

The effects of music on the cardiac resuscitation education of nursing

students
Sevinc Tastan a,⇑, Hatice Ayhan a, Vesile Unver a, Fatma Ilknur Cinar a, Gulsah Kose a, Tulay Basak a,
Orhan Cinar b, Emine Iyigun a
a
Gulhane Military Medical Academy, School of Nursing, Ankara, Turkey
b
Acıbadem University, School of Medicine, Department of Emergency Medicine, Istanbul, Turkey

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

Article history: Purpose: The purpose of this study is to examine the effects of music on the appropriate performance of
Received 24 February 2016 the rate and depth of chest compression for nursing students.
Received in revised form 15 June 2016 Methods: This randomized controlled study was conducted in the School of Nursing in Turkey between
Accepted 18 June 2016
November 2014 and January 2015. The study’s participants were second-year nursing school students
with no previous formal cardiac resuscitation training (n = 77). Participants were randomly assigned to
one of two groups: an intervention group with music and a control group without music. During practical
Keywords:
training, the intervention group performed chest compressions with music. The outcomes of this study
Cardiopulmonary resuscitation
Music
were collected twice. The first evaluation was conducted one day after CPR education, and the second
Nursing student evaluation was conducted six weeks after the initial training.
Randomized controlled trial Results: The first evaluation shows that the participants in the intervention group had an average rate of
107.33 ± 7.29 chest compressions per minute, whereas the rate for the control group was 121.47 ± 12.91.
The second evaluation shows that the rates of chest compression for the intervention and control groups
were 106.24 ± 8.72 and 100.71 ± 9.54, respectively.
Conclusion: The results of this study show that a musical piece enables students to remember the ideal
rhythm for chest compression. Performing chest compression with music can easily be integrated into
CPR education because it does not require additional technology and is cheap.
Ó 2016 Elsevier Ltd. All rights reserved.

1. Introduction
After cardiac arrest, ischemic injuries occur in the brain and
heart within the first few minutes. Survival rates after the arrest
depend on the immediate and effective application of basic and
advanced life support (Paal et al., 2012). Immediate and correctly
performed cardiopulmonary resuscitation (CPR) prevents
neurological deficits and increases the quality of life of individuals
after sudden cardiac arrest (Abella et al., 2005a; Lee and Low, 2010;
Paal et al., 2012; Rawlins et al., 2009). Because of this, CPR is an
important life-saving technique that increases survival rates by
two to three times (Hafner et al., 2012, 2015; Matlock et al.,
2008), especially when chest compression is performed correctly
(Abella et al., 2005a; Rawlins et al., 2009).
The American Heart Association (AHA) states that since tissue
perfusion during CPR is completely tied to chest compression, such
compression should be prioritized in CPR (Berg et al., 2010). The
primary condition for increasing a patient’s survival rate and
ensuring the efficacy of CPR is to perform chest compression at a
constant rate (Hafner et al., 2012, 2015; Matlock et al., 2008) and
to limit the number of discontinuations as much as possible
(Rawlins et al., 2009). An inadequate number of chest compres-
sions decreases the survival rate (Woollard et al., 2012), whereas
excessive chest compression results in stretching the sternum
and negatively influences blood volume returning to the heart
(Zhou et al., 2014). Accordingly, CPR guidelines suggest between
100 and 120 chest compressions per minute (AHA, 2015) in order
to maintain blood flow after cardiac arrest (Wik et al., 2005).

1.1. Background
⇑ Corresponding author.
E-mail addresses: stastan@gata.edu.tr (S. Tastan), hayhan@gata.edu.tr
(H. Ayhan), vunver@gata.edu.tr (V. Unver), icinar@gata.edu.tr (F.I. Cinar),
Existing studies on CPR reveal that it remains ineffective
glsh_ks@yahoo.com (G. Kose), tbasak@gata.edu.tr (T. Basak), orhancinar@yahoo. (Hafner et al., 2012, 2015; Naushaduddin et al., 2010; Paal et al.,
com (O. Cinar), eiyigun@gata.edu.tr (E. Iyigun). 2012) due to the fact that the number of chest compressions is

http://dx.doi.org/10.1016/j.ienj.2016.06.007
1755-599X/Ó 2016 Elsevier Ltd. All rights reserved.
 S. Tastan et al. / International Emergency Nursing 31 (2017) 30–35
lower or higher than the numbers suggested in AHA guidelines
(Abella et al., 2005a; France et al., 2006; Hunt et al., 2009;
Perkins et al., 2008; Wik et al., 2005; Zhou et al., 2014). Besides,
the guidelines of the AHA (2010), Basic Life Support (BLS) and
Advanced Cardiac Life Support (ACLS) have not been transitioned
into clinical practice (Hafner et al., 2012; Zhou et al., 2014). A study
by Abella et al. (2005b) found that the number of chest compres-
sions per minute for patients with cardiac arrest was below 90.
On the other hand, a study by Wik et al. (2005) on paramedics
and nurses found the number of chest compressions to be
over 120. Therefore, educating health personnel on how to apply
effective CPR is extremely important (Rawlins et al., 2009).
The CPR education of nurses who frequently encounter cardiac
arrest is exceedingly important and compulsory (Hamilton, 2005).
However, the skills gained during CPR education are not long
lasting (Hamilton, 2005), and health personnel are not able to, or
are not aware of, performing the suggested number of chest
compressions (Hafner et al., 2012). Considering this, nurses should
be educated with the most recent and appropriate knowledge
about resuscitation and be able to put this theoretical knowledge
into practice (Sullivan et al., 2015). Since lectures on CPR education
are part of undergraduate programmes for nursing students, the
CPR-related skills of these students have been frequently observed.
However, these studies note that theoretical knowledge and skills
are forgotten over time. The case is no different for graduates of
nursing programs (Madden, 2006; Dal and Sarpkaya, 2013).
Performing the recommended number of chest compressions
per minute during CPR training may be a hard task (France et al.,
2006; Rawlins et al., 2009). In order to overcome this difficulty
and to find the required rhythm, various techniques have been sug-
gested, including music and the use of metronomes (Hafner et al.,
2015; Matlock et al., 2008; Naushaduddin et al., 2010; Paal et al.,
2012; Rawlins et al., 2009). For this purpose, popular songs have
been used worldwide (Matlock et al., 2008) in the application of
CPR. One of these songs used to apply the appropriate rhythm
for CPR is entitled ‘‘Stayin’ Alive”, by the Bee Gees (Hafner et al.,
2015; Rawlins et al., 2009; Woollard et al., 2012). Other music used
widely to assist CPR rhythm includes ‘‘Nellie the Elephant” and
‘‘Macarena” (Oulego-Erroz et al., 2011; Rawlins et al., 2009). Since
neither the rhythm nor emphasis changes for these songs, they
create the effect of a mental metronome and can be easily remem-
bered (Hafner et al., 2012, 2015; Matlock et al., 2008; Oulego-Erroz
et al., 2011; Rawlins et al., 2009; Woollard et al., 2012).
Various studies exist on the use of music in CPR in the context
of the education of medical students, paramedics, and students
from non-health-related fields. Hafner et al. (2012) and Matlock
et al. (2008) used ‘‘Stayin’ Alive” during the CPR training of health
personnel and medical students. Both studies show that music
helped the participants perform the ideal chest compression rate
(Hafner et al., 2012; Matlock et al., 2008). After watching a CPR
education video using the music for ‘‘Stayin’ Alive”,
Naushaduddin et al. (2010) stated that chest compression rates
of emergency nurses and doctors were 117.3 per minute. Similarly,
a study by Oulego-Erroz et al. (2011) on students aged 13–14
showed that music helped the students reach ideal chest compres-
sion rates. Hafner et al. (2015) found that the use of pop music such
as ‘‘Stayin’ Alive” to establish the appropriate chest compression
rhythm was effective among university students. These studies
show that music helped the participants perform the ideal chest
compression rate. However, no studies on music’s effect on chest
compression rates has been conducted among nursing students
who received CPR education for the first time. We predict that
developing musical memory will be easier for participants who
have learned to perform CPR for the first time. This study aims to
analyze the short- and long-term impact of musical memory on
the appropriate performance of the rate and depth of chest
31
compression for nursing students who receive CPR education for
the first time.
2. Methods
2.1. Study design and setting
This research was planned and conducted as a randomized
controlled trial. The study was conducted in the School of Nursing
in Turkey between November 2014 and January 2015. There are
different nursing education systems in Turkey. An integrated
education model is used in the nursing school where the study
was conducted. The curriculum consists of committees. The first-
year committees are interested in four basic nursing concepts
(e.g., the structure and nature of the human body, society and
the environment). The second and third year committees are struc-
tured according to bodily systems such as the heart and circulatory
system and the digestive system. An internship programme is
implemented in the fourth year of nursing education. Theoretical
and applied lessons for CPR are given during the second year
within the context of the heart and circulatory system. Therefore,
participants in this study were second-year nursing students.
2.2. Sample size
The sample size was calculated by using the power and sample
size software package (G⁄ Power 3.1.7, Franz Faul, Kiel University).
Predicting that the ideal number of chest compressions (100–120
compressions per minute) would be 80% for the intervention group
and 40% for the control group, we calculated the inclusion of at
least 27 nursing students for each group in order to achieve 80%
power with a confidence interval of 95%. However, all voluntary
students were included in the study, so none of them could be
excluded.
2.3. Randomization and blinding
Block randomization was used to randomize the participants.
Computer-generated numerical tables were used to randomize
the students, who were divided into two categories based on their
place on the class list. Because most of the academic staff evaluated
the CPR during practice sessions of the CPR education, it was not
possible to apply blinding among academic staff.
2.4. Participants
The participants in this study included second-year students
from a university nursing school (n = 77). While 77 students agreed
to participate initially, 75 continued to participate six weeks after
the study had started. Thirty-nine students were included in the
intervention group, whereas 38 students comprised the control
group (Fig. 1).
2.5. The intervention
Prior to the start of the study an emergency service medical
doctor gave the participants a theoretical two-hour lecture on
CPR based on the 2010 version of the AHA guidelines (AHA,
2010). The same specialist gave an applied CPR lesson using a
traditional CPR mannequin.
Following theoretical education, the students received two
hours of practical training in different classes based on their
groups. During this practice, the intervention group watched a
video of a lecture on CPR with music, and performed chest
compressions with music. This study used the song ‘‘Stayin’ Alive’’,
32 S. Tastan et al. / International Emergency Nursing 31 (2017) 30–35
Assessed for eligibility
igibility (n = 77)
Randomized (n=77)
Allocation
Intervention group (n=39))
Music group
First evaluation (n=39)
One day after education
Lost to follow-up (n = 0)) Follow-Up
Second evaluation (n=37)
Six week after education
Lost to follow-up (for disease) (n = 2)
Analysis
Analysed (n = 38))
Excluded from analysis (give reasons) (n= 0)
Fig. 1. The flow diagrams of the participants through each stage of the study.
which the American Heart Association has recommended be used
for CPR education in order to maintain the ideal compression rate
of 100–120 (AHA, 2015). The song, which has 103 beats per minute
(Hafner et al., 2012), is a modified version of ‘‘Stayin’ Alive” and
features an extra rhythm instrument – the traditional Turkish dar-
buka (Izmir 112). The students in the control group, on the other
hand, performed chest compression over the mannequin without
listening to music. Academic staff accompanied the students dur-
ing this performance. These lectures were given by six faculty
members of the nursing department responsible for CPR education,
with three academics educating each group. Guided by the faculty
members, each student performed at least five cycles of CPR on the
traditional CPR mannequin. Next, the students were allowed to
freely perform CPR.
2.6. Measure
The aim of this study was to determine the performance of
nursing students while applying the ideal rate of chest compres-
sion. The effect of short- and long-term musical memory on apply-
ing compressions in ideal numbers was evaluated one day and six
weeks after the CPR practice. During these evaluations, music was
not played and students’ chest compression application numbers
over a minute were recorded for both groups. In order to evaluate
their performance, each student was taken to the performance
room and asked to perform chest compressions on a traditional
CPR mannequin for a period of one minute. The mannequin had
Excluded (n = 0)
Control group (n=38))
Non-music group
First evaluation (n=38)
38)
One day after education
Lost to follow-up (n = 0))
Second evaluation (n=38))
Six week after education
up (n = 0)
Lost to follow-up
Analysed (n = 37))
Excluded from analysis (give reasons) (n= 0)
a sensor that turned green when the students reached the ideal
chest compression depth of at least 5 cm. However, the sensor
did not automatically calculate the rate of chest compression. As
a result, one of the faculty members used a chronometer to control
the start and end of compressions and to count the number of
absences of green lights during chest compression. The other fac-
ulty member counted the rate of chest compressions per minute.
Next, the faculty members scored the results. Scores between 1
and 99 indicated a lower category (slow), 100 and 120 the ideal
compression category (normal), and 121 and above indicated a
category higher than the ideal rate of chest compression (fast)
(Hafner et al., 2015).
2.7. Data analysis
The data analysis was conducted using the Statistical Package of
Social Sciences (SPSS, Inc., Chicago, IL, USA) 15.0. A single-sample
Kolmogorov Smirnov test was used to test the validity of the data
for normal dispersion. We found that the scores for the Body-Mass
Index and the rate of chest compression were parallel to normal
dispersion (p > 0.05). A t-test was used to compare the means
between the two groups. Pearson’s chi-square test was used to
analyze the categorical variables between the rate of chest
compression, exercise and the smoking habits of the nurses. The
McNemar test was used to indicate the difference between the
categorical variable for chest compression rates conducted one
 S. Tastan et al. / International Emergency Nursing 31 (2017) 30–35 33

day and six weeks after the compressions within each group. The 3.2. Chest compression results
value of p < 0.05 indicated statistical value.
Table 2 shows the rate and depth of chest compressions per-
2.8. Ethical consideration formed by the nursing students and the evaluations conducted
one day (first evaluation) and six weeks (second evaluation) after
Prior permission was obtained from the ethical review board of CPR education. The first evaluation shows that the participants in
the institution (4193/14) at which the study was conducted. The the intervention group had an average rate of 107.33 ± 7.29 chest
informed consent form was read to all students and the students compressions per minute, whereas the rate for the control group
who agreed to participate in the research signed the form. The stu- was 121.47 ± 12.91. Hence, the difference between the two groups
dents were informed of their right to refuse to participate or to was statistically meaningful (p < 0.001). The findings also show
withdraw, and that this would not affect their education in any that the ability to maintain the ideal compression rate (100 120)
way. was significantly higher for the intervention group, compared to
the control group (87.2% vs 42.1%, CI [ 18.88, 9.39], p < 0.01).
We found that more than half of the students in the control group
3. Results (55.3%) performed a compression statistic of 121 and above
(Table 2).
3.1. Characteristics of the study subjects The evaluation conducted six weeks after CPR education
showed that the rates of chest compression for the intervention
Table 1 demonstrates some of the descriptive characteristics of and control groups were 106.24 ± 8.72 and 100.71 ± 9.54, respec-
the participants. All of the participants were female, and their aver- tively. The differences were statistically meaningful (p = 0.01).
age age was 20. No statistically meaningful difference was found The ideal maintenance rate of compression (100 120) increased
between their body mass indexes, and their smoking and exercise for the control group, but the difference between the intervention
habits (p > 0.05). and control groups was statistically significant (86.5% vs 60.5%, CI
[1.32, 9.74], p < 0.01). Besides, nearly one-third of the students in
the control group (36.8%) performed in the low chest compression
Table 1
category (1–99). The success of achieving the ideal depth of chest
Descriptive characteristics of the participants. compression (5 cm) was very high for each group evaluated one
day or six weeks after the CPR education (p > 0.05). When the
Experimental group Control group p⁄
maintenance of the ideal rate of compression (100 120) within
Age/median (IR) 20.0 (0.00) 20.0 (0.00) 0.513a each group was compared, we found no significant difference for
BMI/mean (SD) 21.05 (2.77) 20.92 (4.67) 0.884b
the intervention group regarding the evaluations conducted
Right arm/mean cm (SD) 25.26 (2.40) 25.58 (3.40) 0.637b
Left arm/mean cm (IR) 25 (3.5) 24.75 (4.13) 0.717a one day and six weeks after the education, but the case was the
Smoking opposite for the control group (p < 0.001) (Table 2).
Yes – 1 (2.6) 0.308c
No 39 (100) 37 (97.1)
Exercise 4. Discussion
Yes 13 (33.3) 9 (23.7) 0.349c
No 36 (66.7) 29 (76.3) This study analyzed the impact of musical memory during CPR
IR: interquartile range; SD: standard deviation. education on the rate and depth of chest compression performed
a
Mann Whitney U test. by nursing students in the short and long term. The first evaluation
b
Student’s t test. of short-term memory conducted after CPR education showed that
c
Pearson’s Chi-square test. most of the students in the intervention group could perform the

Table 2
Compressions the rate of chest compressions performed by the nursing students.

Experimental group Control group p

n % n %
The first evaluation
n 39 38
cpm/mean (SD) 107.33 (7.29) 121.47 (12.91) <0.001a
1–99 3 7.7 1 2.6
100–120 34 87.2 16 42.1 <0.001b
P121 2 5.1 21 55.3
Incorrect chest compression rate/median (IR) 0.0 (0.0) 0.0 (0.0) 0.958c
Six weeks later
n 37 38
cpm/mean (SD) 106.24 (8.72) 100.71 (9.54) 0.011a
1–99 3 8.1 14 36.8
100–120 32 86.5 23 60.5 0.012b
P121 2 5.4 1 2.6
Incorrect chest compression rate/median (IR) 0.0 (1) 0.0 (1) 0.482c
McNemar* 0.000 27.0
p* 1.000 <0.001

cpm: chest pressure per minute; SD: standard deviation; IR: interquartile range.
a
Student’s t test.
b
Pearson’s Chi-square Test.
c
Mann Whitney U test.
*
It shows the within-group comparisons of the rates of chest compressions applied at the beginning and 6 weeks later.
34 S. Tastan et al. / International Emergency Nursing 31 (2017) 30–35
ideal rate of chest compression (100–120 beats per minute), as
suggested by the guidelines. However, more than half of the stu-
dents in the control group performed higher than the ideal rate
of chest compression.
The second evaluation of long-term memory conducted six
weeks after CPR education found that the students in the interven-
tion group using mental musical memory maintained adequate
rates of chest compression. Regarding maintenance of ideal com-
pression rates (100 120), no significant difference was found in
the intervention group between their scores for the evaluation
conducted on the first day and six weeks after CPR education. Con-
versely, the members of the control group scored lower in terms of
rates of chest compression in the evaluation of long-term memory
conducted six weeks after CPR education. In fact, one-third of the
members of the control group scored lower than the ideal rate of
chest compression. The difference between the scores of the con-
trol group for the two evaluations of rates of chest compression
may stem from two things. First, some of the students performed
CPR higher than the ideal rates in the first evaluation but
performed ideal rates in the second evaluation. The second reason
is that seven out of the 16 nursing students who performed well in
the first evaluation performed lower than the ideal rate in the
second evaluation. In other words, the CPR rates of the control
group in the second evaluation did not evolve into ideal rates but
were a decreasing trend compared to the first evaluation.
Studies of the impact of music on metronome in CPR education
have been conducted on various samples, including graduates of
health schools, medical students, lay rescuers or students studying
at departments other than those related to health (Matlock et al.,
2008; Rawlins et al., 2009; Naushaduddin et al., 2010; Oulego-
Erroz et al., 2011; Hafner et al., 2012; Paal et al., 2012; Woollard
et al., 2012; Zhou et al., 2014; Hafner et al., 2015). These studies
suggest that the students of the intervention group who performed
CPR with music performed the number of chest compressions sug-
gested in the guidelines. Besides, since music sticks in the mind,
health personnel can perform the ideal number of chest compres-
sions in CPR practices, even after education has ended. Our findings
in this research resemble the findings of other research in the
literature. This study’s findings suggest that musical memory can
help students perform the chest compression rates recommended
in the guidelines.
AHA guidelines suggest that memory can help practitioners
perform the ideal number of chest compressions (Hafner et al.,
2012; Paal et al., 2012). Parallel to the suggestion of the AHA, var-
ious studies have found that using a metronome or music during
chest compression education increases the effectiveness of CPR
by helping the participants perform the ideal chest compression
rate (100–120 per minute) and helps them avoid excessive effort
(Chung et al., 2012; France et al., 2006; Oulego-Erroz et al., 2011;
Roehr et al., 2014). Accordingly, the efficacy of CPR is increased
by using musical memory (Hafner et al., 2015). This study found
that music helped study participants perform ideal chest compres-
sion rates suggested by the CPR (AHA, 2015) guidelines. Our find-
ings are parallel to the findings of other studies in the relevant
literature (Hafner et al., 2012, 2015; Matlock et al., 2008;
Naushaduddin et al., 2010; Oulego-Erroz et al., 2011; Paal et al.,
2012). We believe that listening to music during CPR education
helps the development of mental memory; it also helps attendants
find rhythm during CPR. Besides, we predict that students in the
intervention group of this study who were trained with music will
continue to perform ideal chest compression rates in the future.
4.1. Limitations
There are several limitations of this study. First, the study was
conducted in a laboratory using a mannequin. Hence, the results
may differ from situations in which CPR is performed on real per-
sons. Secondly, the study was conducted at a boarding school.
Although the students were asked not to share their documents,
it is possible the students from each group shared their knowledge
and experience and influenced each other. Finally, the participants
may have different experiences and awareness about using a
musical metronome.
5. Conclusion
This study found that a musical piece that enabled students to
remember the ideal rhythm for chest compression in an easy
way helped them to succeed in performing chest compression at
ideal rates in the short and long-term. Besides, the results of the
depth of chest compression were satisfactory in both groups. The
technique of performing chest compression with music can easily
be integrated into CPR education since it does not require addi-
tional technology and is not expensive. Besides, incorporating
CPR education with music into the curriculum to deal with cardiac
arrest scenarios, and regular repetition of this education, may
enhance health personnel’s expertise and skills in performing
CPR to maximum benefit. Additionally, constantly preparing
equipment in laboratories that are necessary for student’s
self-training may increase the effectiveness of CPR education. We
suggest that further studies be conducted to analyze the impact
of music on long-term memory over more than six weeks.
Conflict of interest
There is no personal conflicts of interest.
Funding
No funding.
Ethical approval
Gulhane Military Medical Academy ethical review
board – 4193/14.
Clinical resources
American Heart Association (AHA) Highlights of the 2010
American Heart Association Guidelines for CRP and ECC. Available
from http://www.guidelines.ecc.org.
Acknowledgment
We would like to thank all the students for the participants’
study. We also wish to thank Dr. Cengizhan AÇIKEL for the
statistical analysis of our study.
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