Music as a Therapeutic Assistant : Strategy to Reduce Work Stress

Dereck Sena de Lima1, Jamilton Alves Farias2, Aurilene Josefa Cartaxo Gomes de Arruda3, Cesar Cavalcanti da Silva4, Maurício Caxias de Souza5, João Euclides Fernandes Braga6, Leila de Cássia Tavares da Fonseca7, Alany Bezerra da Rocha Alves1, Lúcia Raiza Feitosa Alves de Oliveira1, Irany Carvalho da Silva1, Milca Correia Marinho de Araújo8, Thássia Christina Azevedo da Silva9, Laysa Karen Soares de Lima1, Sely Costa de Santana10, Ronny Anderson de Oliveira Cruz11 1 Nurse. Graduated from the Federal University of Paraiba (UFPB), * 2 Nurse. Doctor in Evaluation and Treatments Psychological. Professor of Nursing Graduation (UFPB). *. 3 Nurse. Doctor of Sciences. Professor of Nursing Graduation (UFPB), *. 4 Nurse. Doctor of Nursing from the University of São Paulo (USP). Postgraduate Professor of Health Models and Decisions (PPGMDS/ UFPB). Professor of Nursing Graduation (UFPB). *. 5 Nurse. Member of the Group of Studies and Research in Administration and Informatics in Health (GEPAIE/UFPB). *. 6 Nurse. PhD Professor in the Nursing and Public Health Department. Federal University of Paraiba (UFPB). Coordinator of the Research and Extension for Synapse and Anxiety Group, CCS/UFPB. *. 7 Nurse. Doctor of Nursing. Professor of Nursing Graduation (UFPB), *. 8 Nurse. Resident in Obstetrical Nursing at the Health Secretariat of Recife/ COREMU/IMIP. Recife, Pernambuco (PE), Brazil. 9 Nurse. Graduated in Nursing from the Mauritius University of Nassau. Recife, Pernambuco (PE), Brazil. 10 Nurse. Specialist in Pediatrics and Obstetrics. *. 11 Nurse. Specialist in Activation of Processes of Change in Higher Education of Health Professionals. Professor at the University Center of João Pessoa (UNIPÊ). *.


Introduction
The term stress was first mentioned in the mid-1930s by the endocrinologist Hans Selye (1907Selye ( /1982)), who observed the similarity of some symptoms in patients, regardless of the cause of the disease or its diagnosis, what he called the Sick Syndrome [1] .In 1936 he defined "stress" as "the nonspecific result of any demand on the body, whether of mental or somatic effect, and stressor, as any agent or demand that evokes stress reaction, whether physical, mental or emotional" [2].
Nowadays stress can be understood as a need to adapt or balance an organism to the pressures imposed by the environment [3].Based on this definition and from their studies, the three-phase model was developed according to the intensity and duration of exposure to the stressor agent.In the first characterized phase of alert, the body prepares itself to fight against some possible internal or external threat, where the release of adrenaline happens, in order to increase the heart rate and consequently the blood flow [4].
With regard to the second phase, of resistance, this causes physiological, chemical and metabolic changes in the organism, which adapts to the conditions arising from the threat, thus creating conditions to resist stressful situations, where the organism itself seeks a resolution mechanism for the problem.
The third phase, called exhaustion, is characterized by prolonged exposure to stressors, as a consequence of the prolonged metabolic effort during the resistance phase, there is a gradual wear, which can lead to complete exhaustion, and eventually to systematic metabolic collapse.
Although Selye has classified the three phases of stress (Alert, Resistance and Exhaustion), another phase of the process was identified, both clinically and statistically.[5].This new phase was given the name of quasi -exhaustion, for being between the phase of resistance and the phase of exhaustion.This newly identified phase is characterized by a weakening of the person who is not able to adapt or resist the stressor.The diseases begin to appear, however, they are not yet as serious as in the phase of exhaustion.
In the quadrifásico model created by the author LIPP, where he prepared a manual of the Lipp Adult Stress Symptom Inventory (ISSL).The stages are called Alert, which is the positive phase of stress, characterized by the production of adrenaline that makes the person more alert, strong and motivated.

(Table 1)
It becomes important to know the factors that lead the professional to stress, especially of the worker who works in the health units, because Table 1.Stages of stress according to Lipp's model.

Endurance phase
Where the alert phase maintained for very long periods or if new stressors accumulate, the body takes action to prevent the total wear of energy, appearing the phase of resistance.An increase in cortisol production occurs, leading to a drop in productivity, predisposing the body to vulnerability to viruses and bacteria

Almost-exhaustion phase
When the tension suffered exceeds the limit of the organism in dealing with the stressor agent, influencing the individual's physical and emotional endurance, there is a lot of anxiety at this stage, the person starts to try hard enough to think lucidly, make decisions, smile and work, these moments of normal functioning are interspersed with moments of total physical and psychological discomfort.

Exhaustion phase
Is the most negative phase of stress, characterized as pathological.This is the moment when a very large internal imbalance occurs.The person goes into depression, can not concentrate or work.Their decisions are often unthought.Serious illnesses can occur, such as ulcers, hypertension, psoriasis and vitiligo.

Stress
Is a hotly debated current theme, because this brings a representation of one of the factors that cause the transformations in the organism of the individual, may lead to serious consequences, including death.Work-related stress, also called occupational stress, refers to the worker's inability to adapt to the demands of work and to those he perceives [6].
they are often exposed to several occupational stressors that directly jeopardize their well-being.Among these, we can highlight the long working days, the insufficient number of professionals, the lack of professional recognition, the high exposure of the professional to the chemical and physical risks, as well as the constant direct and indirect contact with the suffering associated with pain and even death [5].
In the aspects related to the nursing professional as a health worker it is noticed that these are generally exposed to several adverse situations in their workplace, which predisposes the confrontation of factors that facilitate the emergence of stress, being this one of the main causes of disabling and even lethal disorders and pathologies [7].
Among the areas of action of the nursing team, it is observed in everyday life that professionals working in primary care have physical, emotional, it is believed that this fact is often related to problems and situations experienced during the work routine, where it predisposes the professional to the commitment of his quality of life [8].Therefore, people in situations of stress require improvement in quality of life, being necessary the development of strategies to cope with these stress-triggering situations [9].
In view of the above, it is perceived that the impairment of quality of life and work overload trigger stress, which is necessary to the search of complementary activities of alternative therapies of low cost that can be realized in and/or out of the work environment.
Complementary activities within the health area can be seen as cares and actions that aid conventional technical activities.Among some integrative and therapeutic practices can be highlighted to water aerobics, acupuncture, yoga, meditation, massage [10].Among these practices, music stands out as a complementary and integrative therapy, which causes physical, mental and social changes, being used for millennia, as complementary therapy, ai-ding in the care and conventional techniques in the treatment of diverse diseases [11].
In nursing, we have as a landmark the notes on the sound environment of Florence Nightingale, precursor of modern Nursing, that between the years of 1820 to 1910, evidenced the power of music in patient recovery with emphasis on the use of continuous sounds and wind instruments, using music with therapeutic purpose.Other nurses throughout history have also incorporated this resource into the care of wounded warriors, most notably Isa Maud Ilsen, who founded the National Association for Music in Hospitals, and Harryet Seymor [12].
It is noticed that nowadays, the therapeutic practices are increasingly used, however, each service should use those that best meet the needs, taking into consideration the benefits and consequences for the individual's emotional and cognitive development, which music can bring [13] With the perspective of caring for those who take care of stress reduction, besides considering the constant load of stress in the daily life of the nursing professionals in a health unit, practical scenario when in academic stages, the need to introduce music as an alternative therapy was perceived, for being low cost, easy insertion inside and outside the work environment and good acceptance in the various stages of the life of any human being.
The assumption of this study is that music, as adjunctive therapy, influences the reduction of work stress in nursing professionals of a basic health unit.From this perspective, this study aimed to understand the influence of music as a therapeutic assistant in reducing work stress of nursing professionals in a basic health unit.

Method
An exploratory and descriptive study, with a qualitative-quantitative approach, whose research scena-rio was the New Hope Integrated Unit, located in the capital of Paraíba, João Pessoa, has 4 subunits known as Ambulantes, Tijolão, Invaded College and New Hope.
The population and sample was composed of 9 nursing professionals working in the Integrated Health Unit of Nova Esperança, characterized by age, sex, marital status, number of children, family income, professional training, employment ties and weekly work shift.As inclusion criterion it was considered to be acting professionally in this unit during the period of data collection; Agree to participate and sign the TCLE (Informed Consent Form); To be a professional of the nursing team, besides working for a year in the unit.Professionals who did not fit the inclusion criteria did not participate in the research.
This study took into account Resolution 466/2012 that regulates the research carried out involving human beings of the National Health Council -CNS [14].Data collection began after approval of the project by the Scientific Commission of the Clinical Nursing Department (DENC) and the Research Ethics Committee of the Health Sciences Center of the Federal University of Paraiba (CCS/ UFPB), according to protocol no.0508/16, CAAE: 58741916.6.0000.5188.
Data collection was performed through a semistructured interview to characterize the profile of nursing professionals (gender, age, years of service, family income, children, etc.).The second instrument was Lipp's Inventory of Stress Symptoms for Adults [15], which identified the professionals who presented stress and defined the symptomatology and stage of stress in which this professional was identified.Finally, after listening to music, the Musical Listening Questionnaire was applied (QAEM), who collected quantitative information regarding musical listening as adjunctive therapy in reducing work stress.
For the analysis of the quantitative data, Pearson's Chi-square test was used through the software SPSS -Statistical Package for the Social Science of IBM Software, To correlate the profile of nursing professionals with the Lipp Adult Stress Symptom Inventory [15] and the Musical Listening Questionnaire (QAEM).These instruments used in this research enable the disclosure of the level of significance and prevalence of specific items present in the cited instruments.

Results
Among the participants of the study, it was found that the sample consisted only of female professionals (100%), where 66.7% are over 41 years of age, 22.2% between 31 and 40 years, and 11.1% between 18 and 30 years, as shown in Table 2, below.The actuation time varied between 2 years and was up to 19 years, with mean 8.78 (SD = 5.31).All subjects reported working in the morning and afternoon, with a total of at least 8 hours per day.The weekly hours worked in the main job added 40 hours per week for all the women participating in the sample.Despite the already intense weekly workload, 44.4% of respondents reported having one more job, as can be seen in Table 2.
According to Table 2, 44.4% of nursing professionals reported working between 20 and 24 hours beyond regular working hours, on a second job, thus, the total weekly workload ranged from 40h/ week to 64h/week.In relation to family income, it was observed that 66.7% had income below 5 minimum wages, in contrast, 33.3% had income between 5 and 10 minimum wages.
Table 3 shows that 66.7% of the professionals did not present significant stress signals, on the other hand, 33.3% of the professionals presented signs of stress.By reading the data according to the Lipp Adult Stress Symptom Inventory [15], it was identified that all nursing professionals who presented stress were in the resistance phase.
Table 4 shows the correlation between the professionals who presented stress and the specific symptoms of the Lipp Adult Stress Symptom Inventory (ISSL) [15].In the table, we can see that the items are characterized by numerals 1, 2, and 3, which correspond to the specific symptoms on a linear time scale.Alphabetic symbols A and B represent the physical and psychological symptoms.Source: Direct Search symptoms showed a significant association, being characterized by 1A, 2A (symptoms experienced in the last 24 hours), 2A, 2B (symptoms experienced in the last week) 3A and 3B (symptoms experienced in the last month).
In Table 6, we have the Musical Listening Questionnaire (QAEM), developed by the responsible researchers, to collect quantitative information according to the perception of nursing professionals about listening to music.
The result shows the frequency of the scale responses of the Musical Listening Questionnaire (QAEM).The first question aims to classify musical listening as a positive experience, 100% (n = 9), the respondent checked the 'Yes'.
The second question assesses how the professional feels during listening.All professionals felt comfortable, 100% (n = 9).The third evaluates the professional's opinion about the habit of listening to music and its influence on the decrease of work stress, with the same result when marking the alternative 'Yes'.
The fourth alternative, assess whether any service user has expressed opinion about the music.We noticed that 66.6% (n = 6) scored 'Yes, positive opinion'.While 33.3% (n = 3) scored 'No, no one'.The last question assesses if the professionals felt irritated and/or stressed with the chosen musical style, 88.9% (n = 8) scored 'No, not at all'.While, 11.1% scored 'No, I liked it a lot'.

Discussion
In the present study, we can highlight that within the results analyzed in relation to the characterization of the profile of nursing professionals, there is a total female prevalence, which is equivalent to 100% of the sample (n = 9).According to the professionals' profile, we can identify in Table 1, that 44.4% (n = 4) of the sample is made up of nurses, while 55.6% (n = 5) are trained in nursing techniques.
The New Hope Integrated Health Unit is composed of 4 subunits that are: Tijolão, Invaded College, Ambulantes and New Hope, being then, a nurse responsible for each subunit.Nursing techniques perform the relay according to the monthly scale.Within the technical assignments, we have, respectively: vaccine room, procedure room, room for quick exams and home visits, as well as extra activities such as reception and collective health activities.
The Family Health Strategy (ESF) nursing professionals develop their activities with the community, where the reality of the individual is much closer.The problems are of several orders and the internal and external limitations are numerous.These particularities expose workers to physical and/or psychosocial risks, which can trigger an occupational stress process [16].
The nurse of a basic family unit should: perform nursing consultations, request complementary exams, prescribe medications according to the ethical, legal and existing protocols, plan, manage, coordinate and evaluate the actions developed by community health agents and nursing staff, as well as, contribute and participate in the activities of Permanent Education.Among the duties of the nursing technician of a basic unit of the family we find: participate in basic care activities by performing regulated procedures in the exercise of their profession in the FHT and, when indicated or necessary, at home; Undertake health education actions to specific groups and families at risk according to the planning of the team [17].
According to Table 2, about 33.3% (n = 3) of the nursing professionals presented stress, on the other hand, 66.6% (n = 6) showed no signs of stress.From the reading and translation of the ISSL, we verified that all the professionals who expressed the stress situation fall into the resistance phase.
Research shows that most nursing professionals, showed signs and symptoms of stress, especially in the stages of resistance and exhaustion, With emphasis on psychic symptoms such as distress and anxiety, depression, accompanied by other symptoms, especially insomnia [18,19].
It is possible to perceive the relation between the situations faced in the daily life of the work with the consequences that stressful situations reflect in the life of the individual, Causing, among other harm, stress.Meanwhile, Stress may be beneficial in moderate doses, but if continued, the body may find it difficult to maintain homeostasis, its physiological balance, making the body prone to the sensation of wear and difficulty with memory [20].
On excessive stress it is still said that this results in premature aging, depression, anxiety and sexual difficulties.All these symptoms are reversible and the person can be entirely well if adequate measures are taken to cope with stressful situations [20].Regarding occupational stress, this is considered a consequence of the imbalance between the demands of work, the coping capacity and needs of the worker [21].
The Resistance phase occurs when the stressor persists for longer, thus increasing the physical endurance of the individual.Symptoms related to breathing, heart palpitations, circulation and tension in the arteries, return to their previous levels.However, with the continuous stimulus of the stressor, the resistance of the organism is reduced, initiating the phase of exhaustion [22].
In Table 3, we present the cross between the profile of the nursing professionals and the specific symptoms of ISSL.ISSL has 53 specific symptoms that are used to characterize the stage of stress in which the individual is found at that time.From the result we specify not only if the individual presents stress, as well as specify the phase and the prevalent symptomatology, whether physical or psychological.However, in Table 3, we explain the symptoms that presented a significant correlation value at the level of 5%.
Stress is defined as a physiological, psychological and behavioral response of an individual, while it tries to adapt to the demands of the environment and the internal ones, being seen as a stimulating source of balance [23].The items indicated by 1A and 1B correspond to the symptoms experienced in the last 24 hours.The items indicated by 2A and 2B correspond to the symptoms experienced in the last week.The items indicated by 3A and 3B correspond to the symptoms experienced in the last month.
Jaw tightening, insomnia and appetite change were the most prevalent symptoms in the last 24 hours, being characterized by 1A.In the last week, the symptoms that presented significance were appearance of dermatological problems, constant fatigue and also change of appetite, observed by item 2A.And lastly, in the last month, among the prevalent symptoms, extreme change of appetite, excessive tiredness, daily anxiety/anxiety and emotional hypersensitivity, characterized by 3A and 3B.Table 4 crosses the variables of the nursing professionals' profile and the specific ISSL symptoms.The age group showed a significant correlation with increased sweating (1A), Tightening of the jaw/grinding of teeth (1A) and change of appetite (1A).
The number of children showed a significant correlation with the specific symptoms: Node in the stomach (1A), sudden increase of motivation (1B) and dermatological problems (3A).
The family income had a direct correlation with insomnia (3A).While the number of employment bonds and professional training correlated with excessive irritability (2B).
The changes in the world of work provoke direct reactions in workers' lives and health, an unhealthy working environment tends to potentiate the onset of signs and symptoms of stress, as well as the excessive workload, since the increase in the work rhythm is related to the greater physical and psychological detachment and energy consumption of these professionals, which can lead to stress in the personal and professional lives of individuals, reflecting the professional's capacity and the quality of the assistance given to the user of the service [24,25].
The disharmony between the man-work relationship causes several modifications in the health of the individual, due to the work rhythm inherent in the work process.In the area of health, we can point out, tired workers due to long journeys, a factor that influences the appearance of physical and psychic problems, triggering chronic diseases, among them the systemic arterial hypertension and several musculoskeletal consequences, emphasizing also occupational stress [23].
In this way, physical and psychological symptoms may proportionally reflect the performance of the individual's work activities, generating a vicious cycle, which can lead to professional exhaustion, indicative of Burnout Syndrome, and it is necessary to visualize and understand the health professional as a person who cares for and also needs care [16,26].
Given the contextualization, the use of Integrative and Complementary Practices (PIC) has been promoting improvements in the quality of life of individuals affected by several diseases, among them stress [27].
Music has been the subject of studies and discussion over the centuries, among diverse artists, therapists, philosophers and scholars, seeking to understand their influence in the life of the individual, covering the social, intellectual and affective field, also acting in the promotion and recovery of human health.Plato (428/348 BC), specifically, used music as a resource to eliminate his phobias, anguish, and depression.Pythagoras (580/500 BCE) prescribed musical intervals to promote health; And Aristotle (384/322 BC) defended music as an emotional catharsis [28,29].Music helps in stress reduction, cardiac function, relaxation, pain management, among others and has been used in several scenarios as a complementary therapy [30,31,32].
Based on the assumption that music is present in the daily life of several people, being used as relaxation technique, stress reducer and welfare promoter, the benefit of the use of music includes the adequacy of the individual's physiological behavior, reduction of pain and body tensions [33].Being used in health services as a complementary therapeutic tool, capable of promoting a more peaceful and welcoming environment [34].
Music therapy should be performed by a qualified professional, the music therapist, who has undergraduate or specialization training that will use the music and/or its constituent elements (rhythm, melody and harmony), in order to meet the individual's physical, emotional, mental, social and cognitive needs [35].
However, the application of music, studies of its therapeutic effects on health can be performed by other professionals.The study of music and its effects started from the Old Age and continued to be studied in the scientific world from World War II until the present moment by professionals of diverse specialties like: musicians, nurses, psychologists and doctors [36].
Recent studies have pointed out the effect of this therapy on metabolic responses, by establishing the role of music in the regulation of the hypothalamicpituitary-adrenal (HPA) axis in the central nervous system and autoimmune system, key functions in metabolic regulation, where studies evidence the effect of music on cortisol decrease [37].Being effective in reducing levels of anxiety and stress, in addition to promoting the general well-being of individuals [38,39].
Songs similar to heart beats are considered calming, with a beat between 70 and 80 beats per minute.Light music can relieve stress and reduce anxiety by providing harmony and harmony with the environment.Some authors state that calmer music stimulates a hypothalamic response that translates into relaxation, altering the autonomic, immune, endocrine and neuropeptide systems [40,41].
However, the individualized choice of music is a controversial factor, some studies point to favoring individualized choice, while others, affirm the importance of giving the individual the opportunity to choose musical style according to his will, believing that the more familiar the music, the more relaxing it will be for the individual [42,43].In view of this, it is possible to assume that the same music will not generate the same psychological and neurological effects in different individuals [36].
Considering that individuals may react differently to the same musical style, A previous visit was made to the scenario of the study with the objective of probing the genres and musical preferences of the participants of the research and from this to elaborate a play list's suitable for each professional [44,45].However, the number of beats per minute (bpm), the quality of the music track (kbps), the volume (dbs), the location of the sound system (acoustics) and the preference of the professional (gender, description) besides the use of songs with noncyclical melodies, since in this type of melody, the brain is not able to predict the sound sequences, an important fact for the individual to reach a state of relaxation [44,45].
The Lipp Adult Stress Symptom Inventory (ISSL) was cross-checked with the Musical Listening Questionnaire (QAEM), but did not present a significant correlation, since the QAEM is a basic primary instrument that served to elicit information about what nursing professionals think about music at work, and their perception of music as a supporting strategy to reduce work stress.

Conclusion
The present study aimed to understand music and its influence on the decrease of work stress in nursing professionals, as well as the presence of stress, the stage in which it is found and the symptoms that showed greater predominance.
We observed that participants expressed positive opinions about listening to music, thus, it is possible to verify the benefits that this practice can promote to these individuals, in order to minimize potential stressors.
From the results obtained through this research, we can confirm that according to the conception of nursing professionals, the music may reduce the work stress, however, it would take weeks or months to evaluate the influence of music in the face of the symptoms presented by nursing professionals, bearing in mind that stress as a negative factor is a process that can take months or years to settle.
This study concludes that stress is present in the daily life of nursing professionals, in view of this scenario, maneuvers and intervention strategies are necessary to treat professionals in the process of stress, before they progress to the stage of exhaustion and eventually develop more serious pathologies.Being important studies that explore the theme in order to raise awareness among so many workers as managers and organizations, in the search for complementary therapies that can minimize the currently present stress, in the nursing team that receives a daily load of emotions, challenges and problems that provoke and/or potentiate the stress.
It is extremely important, not only for nursing, that more studies with this theme be developed.As well, the need for a greater investigation of the stressors acting on the routine of these professionals and their consequences.
Music, in all its universal versatility, is an elementary millenarian tool of reflection and expression.In addition to provoking emotional reactions, they stimulate memory and thinking, and can bring to the fore old memories of past times.They also serve as a time capsule, where great tales and fragments of world history are stored.They carry with them traces of their origins, culture and civilization.They mark times and great events.They can provoke laughter and crying.Joy and sadness.Turn ordinary into extraordinary.And even when we can not understand what is being said, we can feel it within us, somewhere in the immensity of being, which unfortunately we often ignore.Music is life, music is health.

Table 2 .
Frequency of variables of the profile of nursing professionals.João Pessoa, PB, 2016.

Table 5
above correlates the variables of the professionals' profile with the Lipp Adult Stress Symptom Inventory.We observed that the specific
1A and 1B: Symptoms experienced in the last 24 hours; 2A and 2B: symptoms experienced in the last week; 3A and 3B: symptoms experienced in the last month; A: physical symptoms; B: psychological symptoms.Source: direct search.

Table 5 .
Crossing between the variables of the nursing professionals' profile and the ISSL.João Pessoa, PB, 2016.
1A e 1B Symptoms experienced in the last 24 hours; 2A and 2B: symptoms experienced in the last week; 3A and 3B: symptoms experienced in the last month; A: physical symptoms; B: psychological symptoms.Source: direct search.