Sweet Melodies: Combining the Talents and Knowledge of Music Therapy and Elite Musicianship
Abstract
This article reports on a collaborative short-term project between the Melbourne Symphony Orchestra and the Music Therapy team at The Royal Children's Hospital, Melbourne to provide live music on the Neonatal ward of the hospital. The focus was for the music therapists and musicians to develop their understanding and capability to provide live music in an environment for medically fragile patients. To extend the benefit of this experience, guidelines for future musicians were also produced. The guidelines were created through a process of narratives and discussions which were transcribed, and subjected to a thematic analysis. Mid and final review meetings for the whole team encouraged discussion about the emerging themes and final collation of guidelines. The guidelines were intended to offer guidance for new Arts in Health programs or for solo musicians volunteering in a hospital without such a program.
In 2004 the Melbourne Symphony Orchestra Outreach (MSO) Program initiated a collaboration with the Music Therapy team of the Royal Children's Hospital, Melbourne (RCH). The MSO Outreach Program's purpose was to create opportunities for their musicians to use their talent and skill to re-engage with the community in ways which performing cannot achieve. The RCH music therapy team decided that the Adolescent program would be the most approachable starting point for the musicians and patients. Clare Kildea (2007) originated the In my own time project which showed that such a collaboration was an innovative and successful experience for both the young people and the elite musicians. In 2007, the collaboration was extended with the Sweet Melodies project on the Neonatal Unit (NNU). Music therapy was already well-established on the NNU (since 1996) and as the clinician on that Unit, my idea was to provide live music of the highest quality in that context.
The project was titled Sweet Melodies to identify it as an initiative distinct from the on-going music therapy program. This article[1] offers a description of how such a one-off project can be built to draw communities together, while also growing an understanding of music and music therapy in the hospital for administrators and other gatekeepers.
In some countries, including Australia, there has been a hesitance to engage with the Arts Health field because it often seemed poorly informed, with a less-than-rigorous application of music to the context. The RCH music therapy team saw the collaboration with the MSO as an opportunity to expand the presence of music in the hospital, music therapist's role in the hospital by utilising the music therapist's knowledge of the specific needs of the patient/unit and their music knowledge. The music therapists are members of many treatment teams so why not be part of a creative arts team? By implementing and facilitating arts and health programs in hospitals the music therapist becomes a gatekeeper and establishes themselves as an integral part of the program to promote safe, useful experiences for everyone involved. We also understood from the early programs on the adolescent unit that by engaging in music-making in a context which is not about performance, the musicians gained new insight about their musicianship and an understanding of how music can play a vital and intimate role in people's lives (Kildea, 2007).
Context and Preparation
Hospitals are essentially places of tension & anxiety in which beautiful live music is an aesthetic experience with the potential to change personal energy and the energy of the environment. Bringing positive aesthetic experiences into the hospital has the potential to impact either on the general atmosphere or to distract, relax and energize patients, families and staff. On the NNU, the babies, families and staff form their own micro-community. The well-being of babies, families and staff is inextricably bound by their common experience of promoting the baby's health. The intensity and emotive energy of the environment is at times palpable and not easily dissipated. While families and staff may escape the ward, the relentless experience on the ward means that there is no release valve on the ward itself. In preparations, we acknowledged the energy-laden nature of the ward, and sought to dissipate the energy of the environment, enabling families and staff to remain in the space with less cost to their well-being.
With this underpinning framework, the primary intention of the Sweet Melodies project was to impact on the tension-laden atmosphere of the Neonatal Unit. The further intention was to systematically review the experience of providing that music, so that a set of guidelines could be created for future musicians who wished to play in hospitals.
No-one works on their own on our Unit, and this team had to be just the same. (Nurse Liaison)
As the senior music therapist for the Neonate & Infant Program, I involved my music therapy intern and sought the involvement of a senior nurse from the NNU as both gatekeeper to the project and contextually informed collaborator. Parents were not involved in the team as this would have required a level of ethical approval beyond the time-frame of this clinical project. Parents should be key stakeholders in such an experience, and I would not do this project again without their involvement.
The MSO Community Outreach Co-ordinator and Creative Director selected the musicians based on criteria specified by the RCH music therapy team:
- Capacity to produce very soft music in a mid to low register (about the range of the human voice) to ensure the music was not overly intrusive, nor in the frequency range of the medical alarms (e.g. concert flute).
- Consideration that the experience could be confronting for the musician and perhaps not appropriate for a new mother, an expectant mother or someone who had experienced a powerful event with a member of their family in hospital.
- Space is at a premium on the ward and therefore larger instrument (e.g. harp) may have cause an obstruction. However, we were willing to work with this as needed.
Three experienced musicians and one young musician, providing us with flute, viola, cello and clarinet, agreed to come in pairs for three sessions each over a period of several weeks.
The Sessions
Pilot Sessions
The music therapists piloted the presence of live music (guitar and singing) in the ward environment. Parents commented favourably and staff were more positive than expected. This confirmed the focus of the project as impacting broadly on the atmosphere. Given that pianissimo (pp) was the loudest volume for the guitar in the room without dominating the environment, we determined that locating the musicians in the hallway meant that the music could be played at a more comfortable level.
Orientation Session for Musicians
The hospital team gave the musicians a half-day Orientation session at the hospital, including as description of the Neonatal Unit, the experience of the infants and their families, how the program would unfold and criteria for the music to be played. Each musician was taken around to the NNU and was able to play their instrument for a few minutes to gain a first-hand experience.
The criteria for the music were based on Hanson-Abromeit's recommendations for pre-term and at-risk hospitalised neonates (see Appendix A). The priority was to provide an experience which did not disturb the behavioural or physiological status of infants. For parents, the concern was providing an engaging experience which did not evoke an unwanted emotional response or prevent them from continuing care of their baby. The protocol for each playing session was outlined so the musicians were assured about how each experience would proceed. In discussions following this project, the musicians noted the Orientation session as vital preparation for the experience ahead. They particularly valued the provisional criteria for selecting music.
Scheduling Sessions
Each musician played for three sessions, in different combinations of pairs. The six sessions were scheduled around the musicians performance commitments across nine weeks. Including Orientation and meetings, the whole program took 11 weeks. The first session was approximately 20 minutes of music in one location. With the change in protocol to include playing in two locations along the long NNU corridor, the session duration doubled to about 45 minutes.
The protocol for each session was reflexive, responding to perceived needs both in the moment and on reflection after each session. It is worth noting that the initial brief of quiet, sedative repertoire was expanded to include lightly refreshing, singable music, and that cello and viola successfully combined in their last session to play a few minutes of simple duets.
Preparations Before Each Session
Prior to each session, the nurse liaison reported if there were any key events or considerations from the NNU. The music therapists and musicians began in the music therapy office where we discussed pertinent issues (eg., major events in the NNU and findings from sessions in the interceding time), the musicians played a sample of new repertoire they had prepared, and there was discussion about suitability and possible modifications (eg. key change, tempo, repetitions etc.). Possibilities for the session (eg. playing duets, shift in style of music) were decided upon at this point. The importance of these preparatory steps was evident in the following vignette:
During preparations for the second of his sessions, the cellist offered to play Saint Saens' The Swan which is beautifully poignant and just the sort of music other musicians might be inclined to play. We were concerned about the evocative nature of the piece, but felt this was the opportunity to test such repertoire. We asked him to play it without too much emotional intent and we all agreed that if we saw or heard any negative response while he was playing, he would conclude the piece and immediately play a much lighter piece to shift the atmosphere. He offered Teddy Bear's Picnic, which e agreed seemed a wonderful contrast. When he played The Swan on the ward, the flautist was observing in a room and felt that one of the mothers was becoming upset. She came out into the hallway and made a visual cue to the cellist to finish and let the nurse liaison know about the mother. He finished the phrase and lightly slipped into Teddy Bear's Picnic. The general mood instantly lifted. After a few minutes, the nurse liaison checked on the mother, and she seemed more relaxed. Later, the nurse liaison allayed the musicians' concerns by explaining that her contextual knowledge of that mother led her to believe that this was her general demeanour and not something caused by the music. Nonetheless, we agreed it was the right decision, and the protective protocol had worked well.
Teddy Bear's Picnic was visibly enjoyed every session after this, with people whistling, skipping and reflecting on songs of their childhood. It was this single piece that taught us that lightly refreshing familiar music had an important role to play (see below).
Evaluation to Support Discovery
It is much more confronting than playing in the orchestra where you don't have real contact with your audience. You are dealing with people's vulnerabilities. … It's right on the edge and you're very conscious of people's sensibilities and sensitivities and everything around you, the noise, the machinery, the cribs, the people walking past. (Flautist)
The Neonatal Unit Management Committee gave approval for the program to proceed. Because I intended to use the words of the project team to produce guidelines, I asked the musicians, music therapists and nurse liaison to sign Participant Information & Consent Forms, giving permission to a) analyse their narratives b) quote portions of narratives as illustration, c) make audio and audio-visual recordings for analysis and use in presentation, and d) take photographic images for use in reports and presentations. Evaluation was designed to illuminate the parameters of providing live music, fulfilling an audit rather than research, function. No direct feedback was gathered from the infants, parents or staff, although spontaneous comments were noted without identification.
The evaluation comprised direct experience, documentation of observation and insights, discussions, sound recordings and visual images, and review meetings. All are reported in detail in the next section.
Observation of the Experience
It's been a rough morning; you can feel it in the air. (NNU nurse)
On arrival on the unit, I made decisions about whether to proceed, who would begin, and how they might begin to play. We were fortunate that no session was cancelled, however on two occasions, the team agreed that the atmosphere was too heightened, and the music seemed out of place. This occurred on the day before the entire Unit moved to a new location in the hospital, and another day when they were very short-staffed. After some attempts to ameliorate the situation with changes in repertoire, the program co-ordinator decided to conclude the session. It was recognised that the silence left after the music can also serve a useful purpose.
Through-out the playing, the nurse liaison and I conducted continuous observations of infants, families and staff in each room of the NNU and also in the main corridor where the musicians were playing. Significant events, spontaneous comments and notable occurrences were documented.
Sound Recordings and Visual Images
Excerpts of playing were recorded in the music therapy office prior to the session and on the NNU. The recordings were analysed for musical characteristics within and across sessions. All sessions were photographed and two sessions were video-taped for use in professional and academic presentations.
Documentation of Observations and Insights
Drawing from the qualitative research methodologies of ethnography and phenomenology (essentially the personal story and personal experience respectively), all members of the program team (except the nurse liaison who had to return to nursing duties after each session) sat quietly together after the playing session and wrote their personal reflections on the experience. The nurse liaison completed the same task as soon as her shift of nursing finished that day. I asked the musicians to focus on particular issues:
- the experience of playing the music on the ward
- the suitability of the repertoire they had selected
- the qualities of their playing
- their perceptions of the impact of the music
- their feelings about the experience
- thoughts and questions for next time
I asked the nurse liaison to write about her observations of the impact of the music in the rooms, taking particular note of all responses and comments. The music therapists wrote about the overall experience, the qualities of the music, the experience of people in the corridor passing through, and pragmatic issues of location and duration.
Post-session Discussion
Immediately after the narrative writing, the music therapists and musicians discussed the session, recalling issues from their narratives as needed. I asked questions to elucidate issues from all perspectives. This reflexive process then confirmed considerations and plans for the next session. This discussion was audio-recorded and notes were taken.
Thematic Analysis
The purpose of the narrative analysis was to understand the team's experience of providing music on the Neonatal Unit. We did not seek to understand the impact of this experience for others on the ward beyond our own impressions of that. The areas for consideration were established prior to the analyses. At the outset the broad headings were:
- Repertoire
- How the music is played
- Experience of being on the ward
- Observed impact on infants, families & staff
All narratives, notes and discussions were transcribed into Microsoft Word and subjected to thematic analysis using NVivo 7 Qualitative Software. Key statements were selected and grouped to form themes (Appendix E).
The music therapy liaison analysed all the recorded music samples, making a comparison between how it was played in the office and then modified on the ward. Across sessions she also made a comparison of how music was played the first time as opposed to subsequent playings. The music therapist immersed herself in the recordings and using simple close listening, identified variations in performances based on the musical elements (predominantly tempo, dynamics, register). Key features were grouped into summary statements and offered to the team for discussion at the mid and final review points.
At the mid-program point, I selected key statements from the transcribed narratives and discussions which addressed the headings mentioned. Once noted, these were re-organised into categories which more accurately reflected the statements. The narrative and discussions were reviewed for further additions under these categories. The second raft of analysis took place after all the sessions were completed. As there were new experiences in the latter half of the program, this resulted in further categories being added, particularly, "playing in duet", and "coming more than once."
The textual and musical themes formed the basis of discussions at the review meetings (see below) and subsequently formed a set of themes and exemplary statements to be used as guidelines.
Review Meetings
Two review meetings brought everyone involved in the program together to share and consider aspects of the experience. After three sessions, the mid-review was used to discuss emerging insights from the analysis and make plans for the remaining sessions. There was high consensus on the value of the experience for the musicians, the challenging nature of the environment, the challenge to find suitable repertoire, and the art of playing on the ward.
I didn't know what to really expect, but musically it's a lot more challenging than I thought it would be. (Clarinet player)
After all six sessions were completed the full team met again for a final review meeting. The full set of themes was presented in the form of exemplary statements intended for inclusion in the guidelines. The musicians and nurse liaison commented on the statements and discussed elements which they felt were not adequately represented (eg. the importance of the support team and the content of the orientation session). I then drafted the full guidelines and sent them to the team for final comment prior to the publication of the guidelines. The final themes for the guidelines were:
- Playing music in hospital – general parameters
- Your intention
- Choosing repertoire
- Relaxing the atmosphere with music that floats
- Refreshing people with music that engages
- Connecting with your audience
- Locating yourself on the ward
- Art of playing
- Direct support
- Coming with another musician
- Coming more than once
Meeting the Needs of the Infants, Families & Staff
Perceived Outcomes for Infants
Initial concern for the experience of the babies was allayed by direct observations that many babies (sleeping, feeding, and quietly awake) showed little awareness of the music. This was a desirable outcome as the music was not designed to be a dominant stimulus in their immediate environment. There were some notable experiences for unsettled babies. In the second session a nurse reported that a baby in the far corner had been unsettled (crying and restless) after a rough morning but when the music began the baby alerted to it and calmed down, remaining quiet and stable for about 40 minutes. This saved precious energy she needed to heal and grow. Another mother said "This will help him go to sleep, seeÂ…", as his eyes closed.
On occasions infants were observed looking towards the door when the music began. There were a few occasions during which babies were observed to respond with movements when the music commenced or stopped; mothers were seen to rock their infants quietly in time with the music. There were some notable responses to the music:
Vignette 1
In the very last session, a musician was located outside an Intensive Care Room. Inside a physiologically fragile baby boy was struggling to maintain his oxygen levels. He had been unstable all day. As the music flowed into the room, his oxygen level dropped to an unsafe level. The bedside nurse let our Nurse Liaison know, and she shut the door. The Music Therapy Liaison instructed the musician to play more gently. The baby soon stabilised. I made the decision to conclude the music and move the musician to the far end of the corridor.
This occurrence served to remind us that our cautious use of two informed observers was warranted.
Vignette 2
When the music therapist heard a baby crying, she stepped into his room to check if the music was bothering him. The nurse explained that he was fussing because he was hungry but his Mum was having a much needed cup of tea. The nurse cajoled him for a few minutes, but he soon began to wail. She brought him to the door to listen to the music. As the cello played, the baby stopped crying and furrowed his brow. A few moments later as the clarinet played a smooth rendition of When you wish upon a star, his frown resolved, his body relaxed, his eyes fluttered and he gently fell into sleep.
Perceived Outcomes for Parents
Although we did not actively pursue comments from families and staff, many parents made a point of spontaneously commenting on the music:
In the third session the ‘cello was located between the Intensive Care room and the Expressing Rooms (breast-feeding mothers express milk to be fed to their infants through a nasogastric tube). A mother emerged from the Expressing Room with a full bottle of milk and thanked us, saying, "It's just beautiful. It made my milk flow".
Note: The Nurse Liaison noted that loss of milk supply is a common and anxiety provoking experience for mothers, who are already fatigued and anxious. Helping milk flow was a notable contribution to that mother's well-being.
Parents happily noted the impact of the music on their infants. One mother smiled and said "I wanted to change his nappy, but he's fallen asleep listening to the symphony!" Another who had been present for all six sessions, was disappointed to learn we had finished the program as her baby was particularly relaxed when they played.
For families with older siblings visiting the Unit, the musicians became a focal point. One father would cuddle his two year old daughter while she was entranced by the music. Another father who stood with his mesmerised toddler in corridor commented, "You've tamed the wild beast!" The nurses confirmed that it was the first time that day the toddler had been still or quiet.
While the music was generally well received, it was important to note the exceptions. On one occasion, a nurse requested some music that was "less depressing", meaning lighter music to shift the atmosphere in the room. The musicians were able to shift immediately into some repertoire from Disney films. In later discussion about this, the cellist suggested that the family didn't need to be grounded, but released from the stress, and therefore he had played with that intention.
Perceived Outcomes for Staff
The Nurse Liaison explained that it was both surprising and delightful to the staff that the musicians would actually come to the Unit to play for them. Between sessions they would ask when the next session was scheduled and expressed disappointment if they were not rostered on to work that day.
Staff were keen to listen – they would locate themselves close to the door of the room in which they were working to hear the music more easily, they would pause in the hallway, leaning against the wall, standing with their eyes closed. The experience raised their own experiences of music - they talked about how much their families would have enjoyed it, their own tastes in music, the role of music in their lives, their own musicianship.
I'm not a classical music fan, but I love the way it floats through the Unit. You don't have to think about it, it's just there. The other music [recorded music] doesn't do that. (NNU nurse)
The music did not suit everyone's preferences, and a few nurses did confide that they would prefer more modern music such as the music they listened to on the radio. Two nurses objected to the idea that they should be quieter while the music played, and raised their voices to compete. This confirmed the music therapy team's pre-existing understanding that there is no "one size fits all" kind of relaxation music.
The Atmosphere was Changed in Unexpected Ways
Relaxing and Refreshing
I feel like I could dance to that. It just makes my whole day better. (Nurse, listening to a waltz played by the cello & viola)
The initial criteria for the music were very cautious. Over the early sessions it became evident that it was not only safe and appropriate, but desirable to energise or refresh the atmosphere with an expanded repertoire of familiar, singable music (e.g. folk music, light Disney themes). Analysis of the playing revealed that the musicians also utilised fluctuating articulation, dynamic contrast, and space between phrases and notes.
Being heard
The NNU rooms were located along a long corridor. The nurses at the far end of the corridor commented that they could not hear the music, so we agreed to offer a second episode of playing down the other end of the corridor so the music could be easily heard at that end of the ward.
Despite a noticeable level of ambient noise created monitors, alarms, ventilators and air pressure, the music still impacted on the Neonatal Intensive Care Unit room (NICU). At the mid program review, our Nurse Liaison (an experienced NICU nurse), explained to the musicians:
It's so noisy in there. There's a lot of activity, it's hot and every sound just seems to compound. There are a couple of particularly loud ventilators that we have two of, and when you have three of those in a row and people talking, and then the ward round comes around and the noise just escalates. Added to that, at hand-over time you've got two lots of nurses in there to catch up on what's happening for all the babies, and it's really loud. The atmosphere in there is awful. But I found that the live music didn't add to that. It just cuts through it. We've had taped music in there and it doesn't come across as well. It's just one of those other things annoying you in the background that we have to talk over, whereas I could hear the live music separately. It's really there in the background, and for me, I just thought "aaaah" [like sigh of relief].
On his second visit, the cellist noted that he played a little louder because he had noted a much higher level of ambient noise in the NICU rooms. He emphasised that it was still important to maintain "an intimate mood" and that the quality of sound "still needed to be soft even when more fully voiced".
Meeting the Needs of the Musicians
It's right on the edge and you're very conscious of people's sensibilities and sensitivities and everything around you - the noise, the machinery, the cribs, the people walking past. (Flautist)
The MSO Outreach Program offers musicians a unique opportunity to engage with their music in unexpectedly beneficial ways. The collaborative projects with RCH offered them an opportunity to re-engage with their fundamental musicality and the emotional and human reality of playing and experiencing music. Through the discussion process, the musicians commented that they found it rewarding, but also confronting and at times overwhelming.
Keeping the musicians safe
It wasn't until I got out of there that I realised how much it had taken out of me. (Viola player)
From previous collaboration between RCH Music Therapy and the MSO Outreach Program we knew that this was a personally demanding experience for the musicians. The context is obviously very different from any other performance venue. The exposure to patients' and families' trauma, suffering and anxieties can be a subtle but profound experience. It does not always present itself overtly, but is sometimes a sensation which surfaces after the experience, as demonstrated by Andrew Weiss' beautiful poem at the beginning of this article, written after his first experience on the NNU. The viola player noted that it took several weeks for her emotional response to really surface. Therefore it was always a priority to offer the musicians consistent support both during each experience and afterwards.
It's a really touching and poignant experience. As an orchestral musician it is amazing because it is a very intimate experience. (Cellist Knowing the music is safe & useful)
Occasionally it was observed that the music was inappropriately loud or varied. This was indicated by people in the rooms increasing the volume of their speech to compensate, or an increased tension in the atmosphere. On such occasions, one of the following responses was implemented –
- ask the musician to decrease the volume
- ask the musician to conclude that piece of music and try something of a different character
- ask the other musician to play thus providing a change in timbre, volume, pitch range etc.
- re-locate the musicians to the other end of the corridor where the music was still available but much quieter
- in more serious situation, conclude the music for the day
Location for Playing on the Ward
During the first session, a television crew filmed the musicians playing in the rooms to also capture the responses of families (for the nightly television news). This experience confirmed our decision that playing in the room was not optimal. The clarinet player noted:
The corridor might also be preferable in terms of the music not being so "in your face". The families are staff are free to enjoy (or not!) the music without fear of having the musician know. They can just relax more. (Clarinet player)
In post-session discussion the same musician noted that he felt very intrusive in the room and had the sense that families could not necessarily go about their business, but might have felt that they should sit and listen to the music.
The musicians explained that playing extremely quietly in the room was strenuous for breath control, and became the singular focus of their playing. In listening to the recordings, the music therapy liaison confirmed that it compromised pitching and timbre which sounded inhibited or tentative. Despite this, both musicians agreed that the opportunity to play in the room gave them a much better sense of connection to their audience. Therefore the protocol was amended to introduce the musicians in each room (with their instruments) before they played. Additionally, while one musician was playing, the other musician was encouraged to spend time in each room listening to how the music sounded and making subtle observations of its impact on the atmosphere of the room. Multiple visits into each room gave the musicians a stronger sense of the whole environment and the intention and purpose their music provided on the ward.
The experience of being in the room and listening to the clarinet in the corridor had a very profound effect on me. The single line is a very powerful communicator! The room felt peaceful and at that moment transformed the ambience in a way that I don't think pre-recorded music could. (Viola player)
Repertoire
I've enjoyed it both here and away from here reflecting on it because it does give you a bit of a new take on certain aspects of repertoire and uses of it. (Cellist)
In the Orientation, the musicians were given Brahms' Lullaby as the archetype for choosing relaxing music repertoire. The initial repertoire the musicians chose was indicative of their customary world of classical music. Pieces such as Barcarolle, Swan Lake, Mozart Clarinet Quintet, Intermezzo from Carmen, Gluck's Dance of the blessed spirits. However they found it difficult to find slow music which was not in a minor key (one of the original criteria), or too poignant. Because of this, they broadened their search into more folk and light popular music eg. Danny Boy, Plaisir D'Amour, Anniversary Waltz, Annie's Song. In the debriefing discussion after each session, the musicians were also able to offer each other feedback about the success of the repertoire and make further suggestions. Therefore some pieces were repeated and others abandoned.
Finding pieces that don't have a strong climax are important to choose. Even Danny Boy I felt that climax had nearly too much emotional intent, no matter what dynamic I played it at. (Clarinet player)
Art of Playing
Through an analysis of the recordings made, the music therapy liaison identified how the musicians developed their playing to musically match our evolving insights.
Containing the Experience:
Perhaps the most difficult parameter for the musicians to grasp initially was the idea of containing the emotional affect of the music. For an elite musician it is counter-intuitive to limit the full emotional capability of the music, but across several sessions was more easily achieved.
Practical issues of instrument:
In purely practical terms, musicians gained useful insights about pragmatic issues. The viola player experimented with mutes and found the concert mute was useful on days when the environment was very quiet. The clarinet player noted that it was challenging to play extremely softly for such a long period of time, and recommended selecting equipment that is more suitable for long periods of soft playing – i.e. soft reeds that aren't going to tire you out quickly.
Musical Elements:
Before and after each session, there was considerable discussion about each of the following:
Tempo: We enjoyed on-going debate about tempo. At the outset, I argued for a slow tempo, but the cellist replied that if the tempo is too slow it makes the music static and not spacious. While the musicians all took note of the initial caution, the whole team noted that in playing to impact the environment rather than a specific infant, the cellist was indeed correct. Those listening often requested music with more life and motion.
Register: The initial request for alto flute rather than concert flute addressed the co-ordinator's concern that the concert flute register emulates frequencies of the physiological monitoring alarms. At the very least it becomes part of the medical auditory environment, and at worst it may agitate infants or distress parents. In the last session, the flautist experimented with her concert flute just to test this idea. The music therapy liaison reported a moment when she was observing an infant and her heart rate alarm went off. The pitch of the alarm was the exact same note as the concert flute played in that same moment. The MT Liaison felt no-one in the room seemed to notice, but she found it disconcerting.
All the musicians experimented with register and determined that the middle register of each instrument seemed to offer the most comfort through warmth and depth.
They have done a beautiful job of internalising the music and audience, evident through their dynamic, tempo, tonguing, elongated phrasing and cautious effect of maintaining a slow rocking tempo. (Music therapy liaison)
Coming with a Partner
The Outreach program recommended that the musicians come in pairs to offer each other support. The musicians reported that it was comforting to have a person from their world with them. There were additional benefits.
There was variation in the mood and movement – it was not at all the same – there were fast moving passages, light and shade, and the contrast of the timbres of ‘cello and flute was much better than having two instruments of the same family. More interesting to listen to for those on the ward and we could play the same piece ie. Barcarolle and it sounded different on each instrument. (Flautist)
While three of the four musicians were of a mature age and had significant orchestral experience, one was young and new. The young clarinettist was less constrained by convention, choosing pieces which were traditionally played on other instruments and were deemed inappropriate for his instrument by the mature musicians. However, his adaptation were successful and inspired the experienced musicians in their own pursuit of repertoire.
At the same time, the more experienced musicians had a significant repertoire of all kinds of music at their disposal and were able to call on that for themselves and each other. The experienced musicians were also parents and in discussion it was apparent that they called on their empathy which the young musician was able to appreciate but not call upon.
Just stepping back and listening to/watching Prue play gave me a sense that the presence of the music adds a serene quality to a fairly tense environment. (Clarinet player)
Alternating Episodes
The musicians alternated episodes of playing. The benefits of this were that it gave more variation in the music, the musicians rested briefly, and they were able to observe the impact of the music in the rooms and adjust their next episode of playing accordingly. Brief silences between each piece and each episode provided a rest in the let the atmosphere.
Duets
On just two occasions the musicians played duets. The cellist and flautist shared a few brief bars Barcarolle which enabled the team to quickly determine that there was scope for duets. In the next session, the cellist and viola player successfully played a range of light duets. Our initial concern that it would be too loud was allayed as the musicians adjusted to provide only little more energy rather than double the energy. The lightness and joyful character of this music consolidated the idea that the music should not only relax but also refresh the environment.
The musicians used each other's energy to lift and lighten phrases. (Music therapy liaison)
Coming More than Once
The musicians noted that by coming more than once they developed a greater level of comfort and confidence in repertoire selection and the art of playing in the medical context. They developed a greater awareness of the how the music could serve the needs of the audience and began to develop a greater autonomy in meeting those needs in the moment. Usefully they identified that this is not an experience suited to all musicians because of the demands on emotional well-being and abstract thinking.
Working as a Team
The hospital team was able to take responsibility for the entire experience, allowing the musicians to simply be musicians, while ensuring the suitability and effectiveness of the experience for all the recipients. The musicians identified the presence of the hospital team as critical to their experience, they noted:
Without that support, I would not do it. (Viola player)
Having you there is essential. You know the mood on the ward before we get there and you can gauge if the music is suitable, stopping us if something is bad or getting too sentimental. (Cellist)
It was extremely important. You can't just walk in off the street and have empathy. (Flautist)
I think it may have been important for the staff to see that the musicians were informed by a team of people. (Clarinet player)
Through the orientation and on-going collaboration, the hospital team was able to fast-track the musicians' insights and understanding of how to provide and effective service to the families and staff. The presence of the hospital team ensured that everyone could comfortably enjoy the experience knowing that it was well-considered and safe.
Conclusion
The Sweet Melodies project extended the potential of the relationship between the MSO Outreach Program and the RCH Music Therapy Department. The immediate experience provided to families and staff in the hospital was valuable and appreciated by most who encountered it. The additional on-going benefit was created by a simple thematic analysis of participant narratives subjected to a formal analysis resulting in guidelines for other musicians and hospitals seeking to bring live music into hospitals.
At the time of this report, the project and guidelines had been presented to the Australian Music Therapy Association's National Conference (Shoemark, 2007) and the American Music Therapy Association's National Conference (Oppriecht & Shoemark, 2008). The guidelines have been distributed to interested music therapists, orchestras, and musicians in Australia, and are attached. They have also formed the basis for the Music in Health program at RCH, and been used as precedent and guidance to inform arts health projects at other metropolitan hospitals.
It is entirely possible that music therapists who are also elite musicians could provide this experience in the hospital. However, those music therapists who are functional musicians and not highly skilled risk providing a pedestrian experience which may do a disservice. It is important to note that it was the exquisite skill of the orchestral musicians which created the vibrant success of this experience.
Postscript: In 2008, the cellist and violist returned to test if the guidelines were valid in other areas of the hospital. Consciously using the guidelines to guide them in the Children's Cancer Centre foyer and Outpatients waiting area, the musicians and music therapists agreed that despite differences in the circumstances of the people and the settings, the guidelines provided an appropriately cautious starting point, particularly for musicians who have had no previous exposure to acute healthcare settings, or those who may provide services without support.
Notes
[1]My thanks to the following integral partners in providing the material for this report. From RCH, music therapy liaison Amy Oppriecht, nursing liaison Beccy Maver, In my own time administrator, Beth Dun; from the MSO, Community Outreach Co-ordinator Emma Cochran and Creative Director, Gillian Howell, and the musicians Prudence Davis, principal flautist, Andrew Weiss cellist, Cindy Watkin, Viola player, Mitchell Berrick, clarinet player.
References
Hanson-Abromeit, Deanna. (2006). Developmentally based criteria to support recorded music selections by neonatal nurses for use with premature infants in the neonatal intensive care unit. [Dissertation Abstract] Dissertation Abstracts International Section A: Humanities and Social Sciences. Vol 67(4-A), pp. 1143.
Kildea, Clare (2007). In Your Own Time: A Collaboration Between Music Therapy In a Large Pediatric Hospital And a Metropolitan Symphony Orchestra. Voices: A World Forum for Music Therapy. Retrieved July 7, 2007, from http://www.voices.no/mainissues/mi40007000237.php
Oppriecht, A. & Shoemark, H. (2008, Nov.) Sweet melodies: Combining the talents and knowledge of music therapy and elite musicianship. Paper presented to the National Conference of the American Music Therapy Association, St Louis, USA.
Shoemark, H. (2007, Oct.) Sweet melodies: Combining the talents and knowledge of music therapy and elite musicianship. Paper presented to the 33rd National Conference of the Australian Music Therapy Association, Melbourne. [Recipient of the Excellence in Conference Presentation Award]
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Appendix A – Initial criteria for selecting repertoire
Characteristics of the music (from Hanson Abromeit, 2006)
- A steady speed or tempo
- Consistent volume or dynamics
- Few, if any, abrupt changes
- Structured and organized form
- Soothing and comforting
Concern for the parent
Music is evocative. This is not a therapy session, so please avoid:
- Minor keys
- Music with a religious feeling
- Poignant, sad music
Promoting a peaceful environment
Music is evocative. Please consider:
- Music which promotes a calm atmosphere
- Music which promotes deep breathing eg. expansive phrasing
Musicality
Volume: Our single greatest issue in the NNU rooms is the volume of orchestral instruments. Across the pilot sessions we have determined that the dynamic range is approximately pp – mp. We understand that this does not provide much scope.
Tempo: Selections will need to be played approximately Andante. This might suggest that that an Adagio would be a good choice, however many Adagios are highly evocative, so take care.
NB. We have assumed that pre-composed music would be your choice, but you are welcome to improvise.
Hanson-Abromeit, Deanna. (2006). Developmentally based criteria to support recorded music selections by neonatal nurses for use with premature infants in the neonatal intensive care unit. [Dissertation Abstract] Dissertation Abstracts International Section A: Humanities and Social Sciences. Vol 67(4-A), pp. 1143.
Appendix B – Music in Health: Guidelines for Musicians Playing Music in Hospitals
Download Music in Health: Guidelines for Musicians Playing Music in Hospitals [pdf]
