A qualitative exploration of the perceptions of music use by healthcare professionals in the operating theatre (the BACH study)

Abstract

Background music is commonly played in operating theatres and is perceived by many health care professionals (HCP) to reduce stress and fatigue. However, objective psychological and physiological evidence supporting these benefits remains limited, leaving a gap between HCPs’ perceptions and the measured experience. The Background Auditory Conditions in Healthcare (BACH) study aims to qualitatively explore HCPs’ experiences, beliefs and perspectives regarding the use of background music in the operating theatre. Semi-structured interviews were conducted with seven HCPs including surgeons, anaesthetists, and theatre nurses recruited via purposive and snowball sampling between February and November 2024. Data were analysed using qualitative content analysis, with themes developed through open coding, collaborative review, and iterative refinement using a critical realist epistemology. Three surgeons, two anaesthetists, and two nurses from general, vascular, and ENT specialties participated in interviews. Five major themes were identified: (1) Team cohesion reflected in music (2) Music contributes to therapeutic space, (3) Music is not a panacea, (4) Power and protection play out through music and (5) Music as an environmental cue, encompassing nine subthemes. This study highlights the multifaceted role of music in the operating theatre, as perceived by HCPs. While music promoted team cohesion, elevated shared mood and was identified to have therapeutic value for patients and staff, it was also perceived to create or exacerbate interpersonal tension, reinforce hierarchy and disproportionately impact some individuals negatively. Background music also functioned as a situational cue, helping HCPs interpret the immediate OT environment.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-026-46401-4.

Introduction

It is common to hear background music playing in operating theatres (OTs) around the world^1–6. Most surgeons enjoy having music in their OTs and report that it improves their temperament, lowers the perceived mental fatigue of procedures, and reduces how anxious or stressed they feel⁵. Although intra-operative music is widely perceived to affect surgeon stress, there is limited objective physiological and psychological data to support this assertion¹. Recent efforts to quantify the effect of music on the operating surgeon in both clinical and simulated settings did not show significant differences in surgical performance or stress parameters between music and non-music conditions^7–10. This persistent gap between HCPs’ reported perceptions and the measurable effects of OT music suggests that music serves functions that are relational, contextual, and social, and may not be readily captured by quantitative methods alone. Qualitative inquiry is therefore a necessary step in more deeply understanding these dimensions, and in informing the design of future research and practical guidance around OT ergonomics and staff wellbeing.

The Background Auditory Conditions in Healthcare (BACH) study therefore aimed to explore the perceptions of music use of HCPs who work in OTs, in the context of their beliefs, musical backgrounds, experiences of stress, and interpersonal dynamics.

Methods

Design and qualitative analysis

Qualitative semi-structured interviews were conducted as part of a broader mixed methods study. The qualitative data was analysed using qualitative content analysis using both an inductive and deductive approach (referred to as an ‘abductive’ approach by Graneheim and colleagues, which reflects a back-and-forth process between inductive and deductive approaches)¹¹. An abductive approach is particularly well suited to mixed methods research in which the qualitative component is informed by existing quantitative data, theoretical frameworks, or predefined categories. The analysis was framed by a critical realist perspective, underpinned by the assumption that an objective reality exists, but our understanding of it is shaped by our experiences, language, and social context¹². This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines¹³.

Ethics

This study was approved by the New Zealand Health and Disability Ethics Committee (HDEC 2023 AM 9287). The authors confirm that this study was performed in accordance with New Zealand National Ethical Standards for Health and Disability Research and Quality Improvement and the Declaration of Helsinki. All participants provided written informed consent and to ensure anonymity, each participant was assigned a numerical label (e.g. P1).

Reflexivity and positionality

The lead researcher and interviewer (AN) is a practising vascular surgical registrar with prior quantitative research experience in this field, which may have influenced participant rapport, interview direction, and initial analytical assumptions. To mitigate this, independent coding was performed by a second researcher (SE) from a non-surgical background, and discrepancies were resolved through structured discussion. The interdisciplinary composition of the research team, including surgery, physiology, and psychological medicine, provided multiple interpretive perspectives during thematic development.

Recruitment and participants

Recruitment occurred from February to November 2024 and was conducted through purposive and snowball sampling. Eligible participants were HCPs who were qualified or training surgeons, anaesthetists or theatre nurses from any surgical subspecialty, aged 18 years or older, and of any gender. Emails were sent to potential participants, and agreeable respondents were contacted and screened for eligibility (AN). Efforts were made to recruit a range of experience levels, occupations and sub-specialties of HCPs to increase the diversity of perspectives. Participants were recruited from major metropolitan hospitals across three New Zealand cities. Recruitment ceased once the researchers determined that saturation had been reached.

Interview procedure

A semi-structured interview schedule was developed by the research team (AN, AS) to explore participants’ experiences and perceptions of music in the operating theatre and were informed by prior quantitative survey work conducted by the authors (see Supplementary Material)^4–6. Initial questions focused on participants’ occupational background, including subspecialty and work context. Subsequent sections explored six key areas: (1) personal engagement with music, (2) intra-operative stress, (3) practices and preferences of intra-operative music use, (4) beliefs regarding the music, (5) negative experiences and conflict (6) the influence of music on wellbeing. All interviews were conducted in-person, in a private setting, in a single sitting by one interviewer (AN), with field notes taken to document non-verbal cues and contextual information. Probing questions were employed, where appropriate, to elicit further detail and encourage reflective responses. Participants were informed of their right to discontinue the interview at any time without consequence. All interviews were audio-recorded and transcribed verbatim post-hoc.

Data analysis

Qualitative content analysis was selected as the most appropriate analytical technique¹². The analysis process followed three main stages. The initial stage involved inductive open coding, performed independently on two interviews by two members of the research team (AN and SE), each generating a provisional codebook based on their individual interpretations of the data. Grouping was based on conceptual similarity and shared meaning, whereby codes describing related experiences or perceptions were clustered together and labelled to reflect their shared content. Discrepancies were discussed and a unified codebook was developed. This codebook was then applied independently and iteratively by both coders (AN and SE) to the remaining five interviews, with discrepancies resolved through discussion with a third researcher (AS). Quotations that accurately reflected the breadth and depth of participants’ perspectives, while preserving the context and intent of the original responses, were identified and mapped during the coding process. Second, codes were grouped into themes and subthemes, and a refined coding framework was developed through discussion with additional researchers (AN, SE, AS). Representative quotations were selected based on their clarity, relevance, and ability to exemplify the underlying patterns observed across the dataset. Finally, the codes and sub-themes were mapped to allow for broader structured interpretation. Data coding and thematic grouping were organised and managed using Microsoft Excel to facilitate systematic categorisation and comparison¹⁴. Thematic saturation was determined operationally by the absence of new codes emerging during independent coding of successive interviews, first observed after the fifth interview and confirmed across the sixth and seventh. Given the study’s narrow focus, this sample size was deemed sufficient to meet the study objectives. The final analysis was reviewed by AS.

Results

Seven participants were interviewed, comprising surgeons (n = 3), anaesthetists (n = 2), and theatre nurses (n = 2), representing a range of surgical subspecialties and levels of experience (Table 1). The cohort included three male and four female participants, and of the five doctors, three were consultants. The specialty areas represented by the surgeons and nurses were general surgery, vascular surgery and ear nose and throat surgery. Qualitative content analysis identified five major themes and nine subthemes, which are presented in Fig. 1 as a thematic map. Number of contributing participants to each theme are shown in Table 2. Participant quotes are shown in italics using anonymised labels (e.g. P1, P2) to preserve confidentiality. Interviews ranged in duration from 31 to 57 min (mean 42 min) and no participants withdrew from the study.

Table 1.

Participant demographic characteristics.

Participant	Role	Specialty	Gender	Years of experience in this role
P1	Training Surgical Registrar	Ear Nose and Throat Surgery	Male	< 5 years
P2	Training Surgical Registrar	General Surgery	Female	< 5 years
P3	Consultant Surgeon	General Surgery	Female	< 5 years
P4	Senior Theatre Nurse	Vascular Surgery	Female	> 15 years
P5	Senior Theatre Nurse	General Surgery	Female	< 5 years
P6	Anaesthetic Consultant	General Surgery	Male	< 5 years
P7	Anaesthetic Consultant	General Surgery	Male	> 15 years

Fig. 1.

Thematic map of healthcare practitioners’ perspectives on music in the operating theatre.

Table 2.

Number of participants who contributed to each identified theme and subtheme.

Theme	Sub theme	Number that contributed to the theme
Team cohesion	Bringing together	5
	Showing cracks	2
Music contributes to therapeutic space	Sound as therapy	6
	Functional distraction	4
Music is not a panacea	Unhelpful distraction	5
	Music as stressor	6
	Music reflects diversity	5
Power and protection play out through music	Hierarchy, safety and equity	6
	Regulation as protection	5
Music as an environmental cue		5

Counts reflect unique participants who made at least one relevant comment during coding. Participants may be represented across multiple themes and subthemes where applicable.

Theme 1. Team cohesion reflected in music

Music in the operating theatre was described as promoting camaraderie, teamwork and shared mood. This effect was noted to be experienced by those in the room when music was playing, and an effect that was intentional by those choosing the music. The way music is used may reflect underlying collaborative or contentious team dynamics and mirrored elements of theatre teams, as explored in the subthemes below.

Subtheme 1.1. Bringing together

Music was widely reported by our participants as contributing to a positive work environment and being used to bring the team together.

“It’s more noticeable when there’s something on that everyone is enjoying and the team is working well together, then you’ve got a good buzz and a good vibe across the whole theatre team. There was a point in the afternoon where three circulating nurses were all having a little dance in the back and everyone was just having a good time and it was pleasant, everyone was on board, things were on track, and it was a nice time.” (P2).

The presence of music could act as a low-stakes and informal social catalyst, where discussions about musical preferences could open the door to more personal exchanges, fostering interpersonal connection. One participant described how “music suddenly becomes something that you have in common, so you start talking about it [you have] some casual banter, and then you get to know that other person” (P6), while another reinforced that music “does have a big impact on teamwork and how it runs” (P4). Music thus functioned not only as background noise, but as a relational tool that subtly shaped team culture and communication.

Even when the music playing in theatre was not to a participant’s personal taste, many expressed an awareness of its broader value to the team environment. Rather than focusing on personal preference, a participant described the way music “can often lead to improved kind of team interaction, team morale,” and admitted that “It seems counterproductive for one person to be against it when a majority of the team want to from a team cohesiveness and a theatre dynamic. That is something that I can just tolerate and deal with” (P3). In this sense, music facilitated the demonstration of a collective perspective, weighing shared purpose above individual discomfort.

Subtheme 1.2. Showing cracks

Intra-operative music sometimes created moments of discomfort, especially when there were conflicting reactions to music choice or volume. What was enjoyable for one person could be distracting, irritating, or even stressful for another. A participant described a “surgeon who used to play classical opera…. No one else liked it. He did. And it sounded terrible. And he’d be doing his stuff and enjoying it. It’s all that screaming women stuff. ‘Soprano’…And after a while you just turn it down or turn it off.” (P7). At times, these conflicts may also remain unspoken, especially in hierarchical environments where staff felt unable to voice dissent, for example another participant remembered times when “ 90 s female ballads [were] on, and it’s been quite painful. And country music from an American surgeon was also quite painful when it was on for about 15 hours” (P2).

Efforts to avoid these moments of discomfort may unintentionally reinforce existing hierarchies, where deference is to the most senior clinician or the surgical team. One participant suggested “in an ideal scenario, it’s the surgical team that chooses” (P1). While this approach may minimise overt disagreement, it may also limit equitable and inclusive decision making – over time risking entrenching bias around who has the authority to choose music and perpetuating unequal dynamics.

This kind of discourse can provide subtle indicators of interpersonal friction or division within theatre teams, suggesting deeper tensions relating to communication, mutual respect and team cohesion, and revealing broader patterns of disregard or dominance. One participant described how his only option when faced with music he couldn’t tolerate was to end his involvement in a case, detailing how he “just walked out. I got someone else to take over. I’ll never work with that person again…do you know Marilyn Manson? That’s what he would play. Start to finish” (P7). Another detailed ambivalence toward the process of finding team music when “unless I’ve gone through and asked everybody, I just can’t be bothered to go and find something…trying to please other people seems like hard work…” (P3). These experiences highlight that discomfort regarding music may reflect a team navigating a shared space poorly, without a collective approach to decision making.

Theme 2. Music contributes to therapeutic space

Music was described as shaping a therapeutic environment by promoting calm, focus, and emotional regulation, contributing to both patient wellbeing, individual concentration and collective performance.

Subtheme 2.1. Sound as therapy

Participants noted that music had a noticeable impact on mood within the operating theatre, often creating a more relaxed and positive atmosphere. This mood-enhancing effect was extremely personal and related to participants’ lived experience, evidenced by a participant noting “music is one of those art forms that is an incredible expression of humanity. I think it does have a huge impact on us. And I think a world without music will be a very sad world” (P4). At times this effect was even observable by other HCPs, with one participant describing how “some of our registrars get a little bit more uptight when you can just hear the consultant talking to them. When there’s background music, they’re a little bit more relaxed” (P6). Some participants described consciously selecting specific types of music to influence their own psychological state, particularly their level of self-confidence before or during a procedure. “I made a ‘confident person’s’ playlist to play in endoscopy, because it’s not something that I’m particularly good at. I thought it was good to have a reasonably upbeat and confident playlist” (P4). Rather than serving as background ambience, it became a deliberate psychological tool, and a personal choice to aid performance and self-affirmation.

Music was similarly used as a therapeutic tool with the intention of relaxing patients, particularly in procedures where the patient remained conscious. A participant described a birth where the parents requested “the Lion King ‘Circle of Life’ which was really amusing for the rest of the team” (P3), while another noted that they would “ask patients if they want to listen to … I think there’s quite a lot of evidence with the local [anaesthetic cases] that having music going is nice for the patients” (P4). Music was viewed as a tool to ease anxiety, providing psychological comfort and improving the patient’s theatre experience. Interestingly, this perceived calming effect on patients may have flow-on benefits for the operating clinician, aiding them in feeling at ease and focused. A participant admitted, “if the patient is awake, I’m inherently a bit more stressed. And so, I would rather the patient is comfortable…they can just kind of get into the music and be settled and then I can do my own thing” (P2).

Subtheme 2.2. Functional distraction

The distracting properties of music were repeatedly proposed by participants as a mechanism by which music was helpful for patients. Music could shift attention away from the clinical environment or the discomfort of the procedure, “Having music going is nice for the patients, it sort of softens the noise if they’re on monitoring, that’s quite a distracting thing for patients. They’re not used to it, we are, so local [anaesthetic cases] I think I would usually try and have music playing” (P4), a sentiment reinforced by another participant who expressed that “the last thing you want is silence. You want some distraction for the patient” (P1). Musical redirection helped support patients through surgery, as an adjunct to pharmacological and procedural interventions.

The distracting nature of music on staff members was also seen as favourable by some. Rather than detracting from performance, mild distraction was viewed as mentally refreshing, “you want something, some noise, some kind of pleasant background” (P2), while another participant admitted “it’s a nice distraction and not in a way that I think will impair my workflow…almost like a way of enforcing a micro-rest.” (P1). Music thus broke monotony and reduced cognitive fatigue. Another participant noted the privacy background music could provide, because “when there’s no music…you can hear every little…you can have casual conversation when there’s some background music, not like when everyone can hear whatever you ask…It feels awkward somehow” (P6). In these contexts, the distracting nature of music was seen as a positive modulation of the environment.

Theme 3. Music is not a panacea

While there were positive elements of background music recognised, participants highlighted that it is not universally helpful—its impact varied by context, task demands, individual preferences, and team dynamics.

Subtheme 3.1. Unhelpful distraction

While functional and helpful distraction properties of music were noted earlier, music could also be experienced as an unwelcome cognitive burden that competed for attentional resources—interfering with concentration, communication, or procedural flow. One participant noted, “I’m not a fan of the extraneous noise. I think there are other things that I want to focus on…I don’t enjoy having an extra source of noise or signal to have to filter out.” (P3). This highlights the dual nature of music in this space, potentially introducing risk or discomfort when not matched to the team and their preferences, “It’s a distraction. It’s not for my benefit.” (P7).

Participants consistently identified certain clinical contexts—particularly high-acuity or emergency scenarios—where music was considered inappropriate, disruptive, or even hazardous, such as ”a trauma…it gets really noisy and…[music] becomes unwanted noise.” (P6) At these times, music “is distracting when it’s really high attention stakes.” (P4). There may also be times during routine surgery, where critical and unexpected times may require less auditory stimulation, “it’s fine while it’s fine and then once it’s not, then you can really want to make it quiet.” (P2).

Subtheme 3.2. Music as stressor

Rather than calming or soothing, music was sometimes perceived to increase stress and acted as a source of irritation or a trigger for sensory sensitivity and overstimulation. This may be due to the type or volume of music being played, and incongruence with emergent events within the operating theatre, “classical music can be quite dramatic and it was a very dramatic point… they were like turn it off because there was bleeding and…when [the music was turned] off it actually did feel a lot less stressful” (P4). This can be influenced by the nature of the case with one participant noting “challenging cases where sometimes if the music’s either too loud or the music is slightly irritating music, it can just kind of grate you a bit” (P2).

The additive stress effect attributed to the music was at times related to underlying interpersonal tensions within the team. One such situation is illustrated by a nurse participant “we have this particular anaesthetist who doesn’t like music, but we do have this surgeon who would love to have music…So, there was a little bit of stress there because, the anaesthetist said, “I don’t like music”, but the surgeon was like, “Oh, I just, I need it to concentrate.” (P6) Disagreements over music choice or appropriateness, or when requests to adjust it were ignored could amplify existing relational strain or create feelings of exclusion or resentment. One participant noted negative feelings towards music related to previous interpersonal interactions, “there are a couple of songs that I just very closely associate with that person…it would, if anything, make me feel more stressed…more tense and more kind of defensive, I guess, because that is the experience I associate with that song.” (P1).

Subtheme 3.3. Music reflects diversity

The diversity in participant responses highlighted how musical preferences vary across individuals, shaped by culture, background, age, and lived experience. Though when these clinicians come together in a shared working environment there can also be misalignment related to their responses to music, “not everybody’s going to like it, and so different people respond to it in different ways. But then, you could say the same thing about silence, so I don’t know if that actually matters.” (P1). Music that is perceived as beneficial to one individual in the theatre, may have the opposite effect on another individual, with one participant recalling, “I [operated on] a young teenage boy, minor case, but he had asked for rap. And it was quite appalling in terms of the language that was going on. And I was quite shocked while he was going off to sleep.” (P2).

There was a reported inherent challenge of selecting music that suited everyone within a shared clinical environment, acknowledging a responsibility in considering the entire teams preferences and comfort, “even if you love misogynistic gangster rap, you probably shouldn’t play it in that environment no matter how relaxing you find it…if you’re picking the music, there’s some responsibility there. You should make sure that it’s good for public consumption.” (P1). While a desire was expressed to foster inclusivity and harmony through music choices, there was also difficulty—if not impossibility—of finding music that satisfied everyone equally, with one participant commenting “people probably resort to a kind of lowest common denominator of essentially pop music…people put on the same playlists, and I get a bit bored.” (P3).

Theme 4. Power and protection play out through music

Music was closely tied to expressions of authority and hierarchy—serving as both a symbol of influence and a mechanism for maintaining or challenging power structures. Policy and regulation may be a way to protect everyone’s needs and preferences.

Subtheme 4.1. Hierarchy, safety and equity

Participants described how decisions around music reflected underlying hierarchies, where the authority to choose, change or control the music frequently aligned with seniority or the operating surgeon, “The more arrogant [surgeons] will just turn it on, straight on, like they own… it’s sort of a power thing.” (P7). In some instances, this dynamic reflected or reinforced existing power structures, where some staff felt reluctant or unable to express their own preferences or discomforts, “You suck it up and it’s fine. I’m an assistant and I’m there to assist. I’m not there to be in charge. It is what it is, and I accept it graciously.” (P2).

Some participants commented on situations where there was shared decision making around music, “I think that can be a team discussion and I think you have to work to the safety of the team in that environment.” (P3). Asking permission, and considering group preferences was valued, “I think you definitely have to get consent from the team…you’ve got to choose music that you know is reasonably well tolerated by most people that are working with you” (P4), without being forceful in the choices of music, “we work with different types of people every day and we cannot force or enforce something on another person that they actually don’t want.” (P6).

Individuals may have requirements related to hearing or health conditions which make them especially sensitive to the auditory environment and as a result, music can have a disproportionate impact on their comfort, concentration, and performance. One participant recounted, “following some of my return-to-work therapy after I’d had a head injury …music in the background was just basically a baseline level of stimulus that then meant that everything else was already it was more likely to cause me symptoms. I was having to put a lot of time and energy into focusing on what other people were saying and filtering out extraneous noise.” (P3) These individuals often experience the OT soundscape more intensely than their colleagues, and background music, while seemingly benign, can quickly become a source of stress or distraction, with another sharing, “I have a hearing problem in my left ear. I can still hear all right, but sometimes…there’s so much noise in theatre, you wouldn’t believe it.” (P7). Accommodating diverse auditory requirements may necessitate a conversation initiated by the affected individual, “I would have an early open discussion with the team at the start of the day to highlight that so try and reduce it becoming a problem later on.” (P3), or by colleagues aware of these requirements, “I have worked with people who have a degree of hearing impairment, and the solution to that is, usually, you turn it down a bit so there’s not so much background noise so you can communicate more easily.” (P1).

Subtheme 4.2. Regulation as protection

Several participants advocated for formal or informal guidelines around music use to set clear expectations, ensure fairness, prevent conflict, and promote a respectful operating environment. One participant stated, “There probably should be a policy…it provides protection for patients and staff in the sense that nobody should be forced to listen to music that they would find offensive or insensitive. And nobody should have the right to force people to listen to something that they don’t want to listen to.” (P3). Rather than imposing rigid rules however, there was support for the idea of “having a framework for it to be discussed so that everyone feels that they have the opportunity to express a preference.” (P2).

However, a contrary viewpoint was that formal policy on music could be seen as institutional overreach, where individuals felt that music use should remain within the domain of interpersonal negotiation rather than bureaucratic control, with one participant suggesting, “I don’t think there should be institutional policy because, with the number of people that we work with in the same room, it becomes kind of self-regulating…Middle managers have more than enough influence, I don’t see a reason to give them more.” (P1).

Theme 5. Music as an environmental cue

Participants described music as a meaningful contextual signal within the operating theatre. It could serve as a non-verbal indicator that influenced how both team members and external observers interpreted the emotional tone, pace, and dynamics of the room. One participant summarised this sentiment, ““if someone comes into a theatre for us and there’s no music, they’ll just be like, what’s going on?… What’s happening? Like, why is there no music? (P6) This may reflect that surgery and the team is progressing normally, “if I walk into a theatre that’s got music going…I know things are going all right. If it’s not playing, I’m like, is there a reason why this isn’t playing …That’s probably just a little cue.” (P4), and an at ease mood in the theatre, “it’s a marker that the environment’s a bit more relaxed.” (P1). The presence or absence of music may also act as a non-verbal marker of power dynamics to a keen observer, “I think, given the fact that surgeons have, at least in my experience, usually picked the music probably reflects the hierarchy in the theatre. And since we should be aiming to flatten the hierarchy, you could argue that we probably shouldn’t be doing it that way.” (P1), indicating a form of ‘environmental authorship’ held by some groups.

The control of music may also be used intentionally or unintentionally as a functional cue to re-align team members helping to reset the tone, maintain or restore cohesion during a case. Often this will be at a critical intra-operative event – marking a transition towards a period of intense work or concentration, “if it is really high stakes…music is not helpful and I think that’s…actually one of those things that cues the whole surgical team into that point…it helps communication because there’s no noise, but two, it also says this is not the time, like it’s a sort of critical pause point.” (P4).

Discussion

The findings of this study indicate a nuanced and multi-faceted role of music in the OT as perceived by HCPs. The results highlight that music contributed to team cohesion and was used with therapeutic intent for both staff and patients; however, its impact varied by context, individual preferences, and team dynamics and its use often reflected existing hierarchical structures. Furthermore, music served as an environmental cue, offering subtle information that could be interpreted by attentive listeners.

Music as a tool to support clinical care

Music has been used since antiquity to enhance wellbeing and alleviate pain and suffering, owing to its accessibility, convenience and low cost¹⁵. For surgical patients, evidence suggests that music has beneficial perioperative effects, demonstrated by anxiolytic effects^16,17, improved pain control^18,19, and lower requirements for anaesthetic or pre-medication^20,21. Music may also attenuate patients’ neuroendocrine stress response to surgery²². Consistent with this, respondents in the present study noted intentionally using music during local anaesthetic procedures to benefit patients. Alam et al. found that among patients undergoing skin lesion excision, those randomised to guided imagery, relaxing music, or control conditions showed no differences in pain, anxiety (STAI-6), or physiological parameters; however, surgeon anxiety was lower in the two intervention groups²³. One proposed explanation is that surgeons may be more at ease, when they are able to focus solely on technical aspects of the procedure, rather than dividing attention to engage with the patient²³.

Interviewees described several positive effects of music on staff, including soothing, relaxation, comfort, improved focus and flow, enhanced team cohesion, masking of ambient silence, and mood-setting for individuals and the team. These findings align with previous research in New Zealand, which reported that most respondents felt that music improved calmness and mood⁴, a result echoed by Ullman et al.² and Makama et al.²⁴. George et al. found that most HCP respondents reported music helped reduce their ‘autonomic reactivity’ in stressful surgeries²⁵. A majority of respondents in George et al. and Yamasaki et al. felt that music improved concentration in the OT^25,26, but findings were equivocal regarding vigilance or focus in the New Zealand study⁴.”

The double-edged nature of music

There is ongoing controversy in the literature regarding the effect of music on surgeons and staff, particularly around distraction and communication^1,27, The findings in this paper may provide further nuance to this ongoing debate. In a recent survey conducted by the first author, approximately one in four surgeons reported that music worsened communication and made the OT environment more distracting⁵. Through deeper exploration of concerns related to the distracting properties of music, it can be noted that these distracting properties were not universally perceived as negative. For example, during long procedures or surgeries performed under local anaesthesia, mild distraction was viewed as beneficial. However, in acute or high-stakes scenarios, the added auditory or cognitive load was perceived as inappropriate or disruptive. Interestingly, in these acute situations, stopping - and later resuming - background music could serve as a contextual cue signalling a shift in team focus or procedural urgency. Furthermore, some participants also viewed music as a source of additional noise that impaired communication. This is supported by simulated studies showing a reduction in accurate speech perception²⁸, and an increase in repeated request rate²⁹. However, we also found that the presence of music could act as an ice-breaker, as a way for team members to connect through personal exchanges, thereby acting as a relational tool. Although difficult to quantify, music’s impact on communication and team culture—alongside its reported effects on mood and relaxation—may help explain findings from recent reviews. A systematic review of over 900 respondents reported that approximately 60% felt music either had no effect or a positive influence on communication³⁰. Similarly, one in four surgeons in the aforementioned survey reported that music improved communication⁵. Moreover, the OT is an emotionally charged environment, and communication can be influenced by emotional responses to triggers within that space, such that negative experiences in this setting may contribute to withdrawal or avoidance behaviours among healthcare professionals³¹. By shaping the emotional tone of the theatre and fostering relaxation and interpersonal connection, background music may indirectly or subtly contribute to improved communication.

A contextual cue

Non-technical skills are a critical component of surgical proficiency. Evidence suggests that training in non-technical skills- especially situational awareness, defined as an accurate understanding of patient, team and environmental factors - may reduce accidents and errors, prompting greater efforts on providing early learning opportunities, often through simulation³²..

In this study, participants expressed how the presence or absence of music was used as contextual information in understanding the theatre environment, signalling mood, normalcy, intensity, stage of the operation and even hierarchy. This cue may represent a passive manifestation of the underlying theatre team dynamic, however, in certain situations, this may have been an active decision by team members, functioning as a non-verbal cue to heighten situational awareness during critical phases of an operation. Participants described instances where lowering the volume or switching off music signalled a shift in focus, drawing collective attention to key procedural moments. This practice reflects the “sterile cockpit” principle from aviation, wherein all non-essential communication and distractions are suspended during high-stakes periods^30,33. Similarly, the control of music could be employed by theatre team leaders as a deliberate tool to align the focus of the wider team during high-demand and critical phases.

A social and hierarchical indicator

A notable thread of hierarchy and power dynamics (Theme 4), was developed in this study, illustrated by how music was used in the OT. This theme can be summarised in three key points: (1) The individual who chose the music could reflect existing hierarchies, whereby surgeons or the most senior HCPs assumed authority to and responsibility for “environmental authorship,” (2) even when music created discomfort, dissent may be left unspoken, perpetuating hierarchical structures, and (3) teams that engaged in shared decision making regarding music selection and accommodated diverse auditory requirements were perceived as more collaborative and inclusive.

The characteristics of medical hierarchy can make it difficult to challenge authority, thereby hampering open communication. Empowering all staff to speak up is critical to addressing communication issues related to medical errors, and this can be promoted by mutual trust, open communication and flattening of hierarchies³⁴. The surgeon-anaesthetist relationship is a foundational dyad that underlies overall team performance in delivering safe and high-quality perioperative care³⁵. There is little research that has quantified the importance of the relationship, however hierarchical differences, poor communication and concerns about the consequences of conflicts have been proposed as barriers when attempting to achieve consensus between the two³⁶. Narratives in this study demonstrated complete breakdown of this critical dyad in the context of disagreements over music. However further qualitative inquiry may elucidate whether conflicts about the operative space are genuinely about the operative space, or indicative of a deeper breakdown in professional relationship. Effective teamwork is widely recognised as essential in the modern OT, though achieving excellent cohesion for a frequently changing team in a reliable and reproducible way remains an ongoing challenge³⁷. While background music may or may not intrinsically alter the way a team communicates, connects and performs – respondents in this study repeatedly remarked that the way in which music was chosen or selected reflected and dictated a positive culture of shared decision-making. This finding may be relevant to institutions, as staff who are happy and engaged in the culture of their workplace may be more likely to engage in meaningful teamwork behaviours such as speaking up with opinions or concerns³⁷. Open and respectful conversations about the auditory environment in the operating theatre may help create opportunities for staff contributions to be acknowledged and valued. This, in turn, may enhance job satisfaction and engagement, with potential downstream effects including reduced burnout and lower staff turnover³⁷.

Inclusivity and health needs

OT noise, particularly when music is present, can impair auditory processing function as was noted by P3 and P7. This can be especially pronounced when the communication involves critical, unpredictable information³⁸. Further challenges exist for deaf and hard of hearing staff and students due to a combination of factors: background noise, the reliance on visual input for simultaneous communication and task performance and the routine use of masks, which can obstruct lip reading³⁹. Theatre team buy-in to creative accommodations - such as Computer Assisted Realtime Translation (CART) - have been suggested to promote success in this environment to hearing impaired team members³⁹. Although no data currently exist regarding theatre staff following head following injury, studies in sports settings have demonstrated disruptions in several auditory processes such as monaural low-redundancy speech recognition, tone pattern recognition and dichotic listening⁴⁰. These impairments may impair effective communication and simultaneous auditory situational awareness within a noisy and critical environment. Furthermore, noise sensitivity – defined as an individual’s reactivity to noise, theorized to be a manifestation of a state of hyperarousal and characterised by annoyance and feelings of being overwhelmed – and hyperacusis, an intolerance of low-to-moderate intensity sounds often accompanied by physical symptoms, may occur following head injury⁴¹. In this study, the addition of music was subjectively detrimental to one participant following head-injury. Further in-depth qualitative research is warranted to identify ways in which the OT environment can be adapted during individualised return-to-work programmes. It is essential the HCPs in leadership roles within the theatre team have an awareness of diverse sensory needs and approach “environmental authorship” with consideration and responsibility, to promote team well-being, inclusivity and performance. It was noted but not fully explored in this study that some participants had pre-selected or prepared playlists for the operating theatre, and analysis of these playlists may provide insight into the types of music played and the reasons for why these are chosen.

Implications for policy and practice

There is growing recognition that music is a meaningful environmental factor in the OT^1,3. Therefore, thoughtful consideration in the context of OT ergonomics and team well-being is warranted. Participants expressed differing perspectives towards institutional policy - some supported for formalised guidance, while others voiced resistance to institutional overreach. An acceptable alternative may involve developing frameworks to encourage team-led, flexible agreements or norms around music use—focusing on respect, inclusion, and situational appropriateness, rather than blanket policies, thereby promoting collaborative control. Where patients are awake or not under general anaesthesia, there exists strong evidence for the use of music to reduce perioperative anxiety and pain⁴². Therefore, in these settings, the choice and presence of music should consider patient comfort, cultural appropriateness, and anxiety management – with consideration to standardisation through simple patient preference prompts.

Strengths and limitations

The primary strength of this study lies in its theoretical grounding and using an abductive qualitative approach exploring an under-researched and nuanced topic with practical implications for staff wellbeing and patient care. Furthermore, the mixed approach that incorporated deductive frameworks existing from the research team’s previous work to create a systematic and comprehensive interview schedule and some initial codes, while also maintaining an inductive analysis to allow fresh narratives to develop from the data, adds depth and richness to the data.

This study has several limitations. The sample was small, however the cohort was intentionally heterogeneous, spanning professional roles, subspecialties, seniority levels and gender, to capture breadth of perspective. Second, we acknowledge that selection bias may have influenced participation in a study of this nature, however efforts were made to interview participants with diverse and opposing perspectives. Thirdly, the study did not include theatre technicians, who form part of the standard operating team in New Zealand hospitals and perform a role comparable to anaesthetic nurses in other health systems. Their perspectives on the OT auditory environment were therefore not captured, and future studies should ensure this occupational group is represented. Fourthly, data were collected from a single country and limited to healthcare professionals (HCPs) working in a westernised, single-payer public health system. As a result, the generalisability of the findings may be limited, though the wider literature suggest consistent views towards music among theatre HCPs across different countries and regions^1,5,6. Finally, the scope and design of this study was aimed at understanding the behaviours, interpersonal dynamics and perceptions of HCPs, rather than the pattern of music usage or demographic differences between categories of HCPs. However, this quantitative data has been published in the authors’ previous work.

Future research

The auditory conditions of the OT may have a disproportionate impact on staff members with hearing impairment or noise sensitivity. Focused enquiry should explore ways in which the OT can be modified to accommodate accessibility. Music is one of many contributing factors in a complex operative environment and in our previous quantitative research we have had limited success in detecting significant differences attributable to this single variable. Therefore, considering qualitative methods to more deeply investigate the nuances of factors such as culture, cohesiveness and hierarchy may enrich the understanding of OT dynamics. The preparation of personalised or pre-selected playlists for operative use, observed among some participants, was not explored in the present study. Examining playlist content and curation rationale may offer a novel avenue for understanding music selection behaviour and its relation to staff wellbeing and team dynamics. Finally, development of a flexible framework to encourage shared decision-making around music use would require follow-on implementation studies to evaluate the impact and utility in the real-world.

Conclusion

This study highlights the multifaceted role of music in the operating theatre, as perceived by HCPs.

While music promoted team cohesion, elevated shared mood and was perceived to have therapeutic value for patients and staff, it was also perceived to create or exacerbate interpersonal tension, reinforce hierarchy and disproportionately impact some individuals negatively. Background music also functioned as a situational cue, helping HCPs interpret the immediate OT environment. These insights underscore the need for thoughtful, contextual use of music in the operative setting. This is especially important when led by those who have “environmental authorship”, who should act with sensitivity to situational factors, team dynamics, and individual auditory needs.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

AN, MK, JPF, AS, and SE contributed to conceptualization. AN, AS, and SE developed the methodology, software, validation, and formal analysis, and curated the data. AN led the investigation. AN, MK, JPF, and AS provided resources. AN, AS, and SE prepared the original draft, visualizations, and contributed to data curation. AN, MK, JPF, AS, and SE reviewed and edited the manuscript. MK, JPF, and AS supervised the project. AN, MK, JPF, and AS contributed to project administration and funding acquisition. All authors reviewed and approved the final manuscript.

Funding

Funding for this work was received from The Waikato Vascular Research Fund, The Surgical Trainees of New Zealand (STONZ) Research Grant, The Australian and New Zealand Society for Vascular Surgery (ANZSVS) and The Royal Australasian College of Surgeons (RACS) Aotearoa New Zealand Research Scholarship.

Data availability

The de-identified datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethics

This study was approved by the New Zealand Health and Disability Ethics Committee (HDEC 2023 AM 9287).