An Exploration into the Perception of Music Interventions in Hospitals amongst Healthcare Professionals

Literature Review

Hospitals aim to provide holistic, patient-centred care. Introducing music could help achieve this. However, few hospitals have the internal structures to support its use. Hole, Hirsch, Ball, and Meads (2015) found that “at present, music is not used routinely perioperatively” (p.1659). With the exception of the Hospital Broadcasting Association (2016), a volunteer-run internal radio station providing radio channels in 200 hospitals, the majority of music interventions are provided through external organisations such as Music in Hospitals and Live Music Now. The factors influencing the lack of music will be explored.

Professionals’ uncertainty about the effectiveness of music interventions and how to fund and incorporate musicians into their practice hinders their use (NHS, 2015). Hole, Hirsch, Ball, and Meads (2015) conducted a meta-analysis including research into any form of music used in the perioperative period of any adult surgery. They found that the scepticism of healthcare professionals, which is largely based on ignorance, prevents the use of music despite sufficient research suggesting it should be made available in medical settings. The medical focus of healthcare professionals is highlighted by Gaynor (2002, p.5) as “we were rewarded … for being fast and efficient, for treating and releasing patients as quickly as possible,” discouraging the exploration of other therapeutic methods. Aldridge (1996, p.59) stated that, “it is necessary to negotiate a common language between those of us involved in the creative arts therapies and those with whom we work in clinical practice.”

Few studies explore healthcare professionals’ attitudes towards music interventions; however, findings show that perceptions improve with increased awareness. In a psychiatric hospital, observing music therapy sessions positively correlated with the value staff attributed to these, although music therapy was still seen as less effective than the work of psychologists and social workers (Choi, 1997). Furthermore, Hillmer (2007) and Metzger (2004) found that witnessing music therapy positively impacted on nurses’ opinions and interest in learning more, and those with greater exposure felt funding was more justifiable. Thorgaarda et al. (2005) found that staff reacted positively to a specialized music environment on a post-anaesthesia care unit. Therefore, exposure to interactive music interventions, in particular music therapy, is shown to have a positive effect on their perceived value amongst healthcare professionals.

Currently, lack of funding in the NHS is an obstacle for new interventions. Robertson, Wenzel, Thompson, and Charles (2017) found that the financial pressures in the NHS have a detrimental impact on the access to services and quality of patient care. However, encouraging the use of recorded music would have minimal costs and could be easily implemented through utilising the devices many patients already own (Cepeda, Carr, Lau & Alvarez, 2006). Research has also shown that the cost of introducing a music therapist is outweighed by the cost reductions in the patients’ dependency on sedative drugs. In some cases this also shortens the length of hospital stay by eliminating the side effects common to some sedatives (Berbel, Moix, & Quintana, 2007; Lepage, Drolet, Girard, Grenier, & DeGagné, 2001; Loewy, Hallan, Friedman, & Martinez, 2005; Walworth, 2005).

This study was designed to explore healthcare professionals’ perceptions of four forms of music intervention ranging from music therapy to listening to recorded music. This will not only contribute to finding effective ways to inform healthcare professionals of how music can be used in a hospital setting, but also show music practitioners how they can make the service they offer easily applicable to this environment.

Approach

This explorative study aims to further understand healthcare professionals’ exposure to music interventions and the perception of their effectiveness. Whilst research highlights the role of music in healthcare, few studies examine the views of healthcare professionals. Through understanding the perspective of healthcare professionals and the factors that influence these, effective ways to inform professionals about music interventions can be established. This can be used to help make music a standardised provision in healthcare. A small follow-up study allowed the researcher to ask questions that arose from the results.

A mixed methods approach was employed allowing in-depth data to be obtained from a broad sample by collecting quantitative and qualitative data. A survey containing closed and open questions was presented as an online self-report or face-to-face structured interview. The follow-up interview was semi-structured allowing the participants to lead the direction of the conversation. The positivist model was used to analyse quantitative data, whilst thematic analysis of the qualitative information provided explanations for the statistical results. The triangulation of the data meant that questions were approached from different perspectives ensuring conclusions were supported by all the results.

Sample

Thirty-one participants took part in this study completing a face-to-face interview (six responses, 19%), an online survey (21 responses, 68%) or an online survey and follow-up interview (four responses, 13%). Participants were placed into four job categories: doctors (10 participants, 32%), nurses (eight participants, 26%), interdisciplinary staff, referred to as other in Figure 8 (eight participants, 26%, consisting of an occupational health doctor, clinical educator, volunteer, play leader, senior physiotherapist, dietician, and two social workers), and retired (five participants, 16%). The participants’ worked on 16 different wards, with some working on more than one ward. A full list of the wards stated is included in the Appendix. For those still working in hospitals the mean length of time in their current job was 8.3 years (SD = 6.9) ranging from 0.3 –24 years. Twenty-five participants (81%) had worked in more than one hospital. Fifteen participants (48%) could play a musical instrument, eight of whom still played (53%). The mean length of time spent listening to music per week was 6 hours (SD = 5.5) ranging from 0–21 hours. Responses to the online survey were removed if they had not proceeded beyond the informed consent, totalling 25 responses. Of the 31 responses included in the statistical analysis there was an 81% survey completion rate.

Purposive sampling was used to ensure healthcare professionals from a variety of roles and settings were included. The hospital local to the researcher, York Teaching Hospital, circulated the study gaining responses from an acute medical setting with little live music occurring. To incorporate participants with a variety of exposure to music interventions staff from a children’s hospital in London with frequent music sessions also took part. The hospital where participants worked was not recorded as the influence of the workplace was not being examined in this research. The survey was forwarded to members of the local medical society accessing retired professionals. The length of time participants had been retired for was not recorded but the effects this could have had on the results is explored. A national music therapy charity also advertised the study. This sampling method gained 27 responses. A further four participants were reached through convenience sampling.

Method

A survey comprising five sections, opening with demographic questions, was created by the researcher, based on the literature. It questioned practitioners’ experience of music in hospitals, their knowledge of music interventions and therapy, the predicted effectiveness of music sessions, and how they can be implemented in the future. Four methods of music intervention were outlined in this study: music therapy, interactive music sessions lead by music practitioners (who were not trained therapists), live music performances where the patients watch musicians playing, and listening to recorded music. The first two categories were combined in some questions to increase the relevance to the participants and make it easier for them to respond. Where this occurred it was clearly outlined to the participant at the start of the question. These were explained clearly to the participants throughout the study. The survey was presented as an online self-report, using the software Qualtrics, or as a structured interview using identical material. The follow-up interview was semi-structured consisting of five open questions, based on responses to each section of the previous survey.

Procedure

A small pilot study was conducted interviewing one participant. This allowed the structure and clarity of the survey to be reviewed whilst giving the researcher an opportunity to conduct an interview. The participant was approached through convenience sampling and did not take part in the main study.

Ethical approval was attained for this study from the University of York before data collection took place. Data collection period was from October 2016 to January 2017. The online questionnaire, sent via email, took 10–15 minutes to complete. Both interviews lasted 20–30 minutes. Interviews from the first study were face-to-face in a convenient setting for the participant (e.g. office or coffee shop) and two participants were interviewed together as this was more convenient for them. Three of the four follow-up interviews were conducted over the phone, giving access to participants from a wider geographical area. Nine of the ten interviews were recorded on two devices and transcribed for analysis. Due to a technical fault one telephone interview was not fully recorded. Detailed notes taken during the interview were used for analysis.

Measurement and Data Analysis

As all participants were presented with the same material, data from the interviews and online questionnaire were analysed together, with the follow-up study analysed separately. IBM Statistical Package for the Social Sciences (SPSS) Statistics 23 was used to produce frequency and descriptive statistics of the quantitative data. A chi squared test was used to show the significance of relationships between variables. Those with a probability of randomness rating of ˂.05 were classed as significant. A non-parametric test was used as the data collected was ordinal or nominal. In addition, the sample size for some of the results varied as not all the participants completed the whole questionnaire. Therefore, finding the median, rather than the mean, provided the most accurate representation of the results. Microsoft Excel was used to generate graphs from these results. In Figures 15 and 16 categorical variables were transformed to metrical in order to create a clearer visualisation of the trend, i.e. nominal data was turned into ordinal data to better represent the results in a graphical format.

Analytic induction of the qualitative data was conducted with an iterative coding process. Responses were analysed repeatedly until the data was comprehensively categorised into themes. To ensure this, the constant comparative method was used producing multiple codes from one case and testing and revising these through analysis of further responses. Codes were clustered to form overarching themes. In-vivo coding, drawn directly from responses, was used. All opinions were treated as meaningful due to the sample size. Tabulations were used to show the prevalence of codes within and across responses and those with a high count were deemed more significant. Quotes are linked to the participant through an individual numerical code, for example P2. P1-6 took part in the interview and P7-10 took part in the follow-up interview. There are 35 labels as four participants took part in both the online survey and the follow-up interview.

The Prevalence and Awareness of Music in Hospitals

Current Exposure and Knowledge of Music Therapy

Figure 1-2.

Figure 1. How common interactive and live music interventions were on the ward. The relationship between these variables is not significant. Figure 2. Healthcare professionals’ experience and the effect of this on their view of music therapy.

Policies within the hospital could prevent music therapists from gaining access to the ward. The time pressures and limited resources make it increasingly difficult for music to be introduced. Results from the follow-up study revealed there was no procedure in place to obtain music therapy within the hospital, meaning staff or patients sourced it themselves. Going through other services such as occupational therapists and the patient advice and liaison service was also suggested.

In addition, 94% of professionals reported little or no knowledge of music therapy. Although level of knowledge did not significantly correlate with the overall lack of music in hospitals, the qualitative responses suggested “ignorance” prevented music therapy from being offered in the hospital (P7). The scientific focus of healthcare professionals was thought to discourage them from trying new interventions, necessitating the need to “normalise it” (P8). The perception of music therapy as less appropriate in acute physical settings and contrary to a scientific viewpoint could be why only 36% of participants were interested in learning more. However, some participants thought introducing music interventions was important to ensure holistic, patient-centred care.

Restricted in what we’re allowed to officially recommend (P9)

Complete lack of knowledge in the hospital setting (P7)

Music is perceived as being a fairly … niche interest (P8)

Truthfully we're just poisoning patients … Ultimately I think 90% of all illness we see can be boiled down to four things - bad food, bad exercise, bad rest and bad stress, and those are the only things. Problem is no one tackles those things, but we're very happy dishing out tablets to try and get people to keep going. (P2).

How to Increase Awareness of Music Interventions among Healthcare Professionals

Figure 3.

How information about music interventions would most usefully be presented.

Fifty percent of respondents thought “watching a session in progress” would most effectively increase awareness of how music interventions can be used more widely in an acute hospital setting (Fig. 3). This was supported in the follow-up study as observing a session as part of Continuing Professional Development (CPD) would be most likely to change healthcare professionals’ opinions. In addition, 28% of professionals would choose a presentation defining the costs, aims, and objectives of music therapy.

Participants were positive towards having a seminar, outlining the ways music can be implemented, in training (63% definitely or probably yes). Informing students early in their careers would promote patient-centred care complementing the holistic healthcare hospitals aim to provide. In the follow-up study, training was thought the best time to increase awareness. However, bias towards medicines amongst healthcare professionals could prevent this being effective.

In addition, increasing patient awareness of the services available to them was thought to help music in all forms become more commonplace. Those in the follow-up study thought information on displays, flyers, and the staff newsletter would raise general awareness in the hospital. The patient-centred approach to healthcare increases the value of feedback and patient involvement in their care. Through increasing general awareness of music in hospitals patients could request it and eventually expect the service to be offered.

when you see for yourself something working, that changes your opinion (P9)

ensure holistic patient-centred care (P35)

you’re so focused on medicines and drug treatments and operations (P1)

it’s something we don’t get exposed to and … you think that medicine is all about just medicine and what you give, but as you get older you start realising that actually medicine constitutes a very small part of care provision … we want to be healthcare providers, we are not at this point in time, we are disease modifiers. … As health care providers what we're doing is we see the cracks, we cover the cracks up, we're not changing the person … Problem is these days people are bored … boredom leads to being sedentary, leads to suicides, leads to stress. … what I’ve realised with the best care in the world at this point in time we don’t get anyone better, and we don’t really improve people's quality of lives, and empowering them, and giving them other things to focus on has to be a good thing (P2).

The Effects of Increased Awareness on Healthcare Professionals’ Perceptions

Healthcare professionals who had more knowledge of music therapy were more likely to think it would have a long term effect (Fig. 4), and those who had observed a live music session were more likely to welcome more live music interventions (Fig. 6). In addition, those who had experienced music therapy were significantly more likely to have considered offering music therapy to a patient (Fig. 5). This is supported in the qualitative data as raising awareness allowed staff to form more accurate opinions. Awareness of music interventions, especially through observing a session, was believed by these participants to be an effective way to alter perceptions of music interventions in hospitals. For one participant, partaking in a music therapy session in a hospice setting influenced her positive opinion of the effectiveness of music therapy in a hospital. Another participant had been part of a project to establish art therapy for patients undergoing dialysis. Witnessing the effects of this on patients’ view of their treatment and engagement with the process positively influenced their view of how music therapy could be used with patients suffering acute physical illnesses. However, awareness of music therapy in other settings, such as with children with disabilities, did mean that two participants did not think music therapy would be suitable in an acute medical environment. Figure 7 contradicts the other findings as those who had observed a music session were less likely to believe the effects were long term.

The role of research outlining how music therapy could be safely implemented was shown in the follow-up study. P9 stated that studies should not only prove the effectiveness of music therapy but also discover how music therapy has a positive effect on people. Current research was viewed with scepticism within the scientific hospital environment by these participants. This could be due to lack of awareness of the research conducted but also shows the need for more evidence. However, it was suggested that solely increasing awareness would not be enough as the whole outlook of healthcare professionals needs to be changed. Therefore, increased communication through collaboration is necessary, especially in research.

Figure 4-9.

Figure 4. The relationship between knowledge of music therapy and whether the effects of music interventions were thought to be long-term X² (2, N = 31) = 9.12, p <.05. Figure 5. Relationship between experience and view of music therapy and whether the participant had considered offering it to a patient X² (1, N = 31) = 9.68, p <.05. Figure 6. Relationship between welcoming more live music and observing an interventions X² (5, N = 31) = 11.36, p <.05. Figure 7. Relationship between observing a music intervention and whether the effects were thought to be long term X² (1, N = 28) = 5.25, p <.05. Figure 8. The relationship between job role and knowledge of music therapy. Figure 9. Relationship between job role and whether participants’ would welcome more live music.

Healthcare Professionals’ Perceptions of the Effectiveness of Music Interventions

Fifty-seven percent of participants thought live music interventions, including music therapy, would have a lasting effect with none disagreeing. One overarching theme was the improvement of psychological well-being, which participants felt was important as illness often limits one’s independence which can affect mental and physical health. Participants also stated that interactive music sessions would help release stress, create a calm atmosphere and allow patients to have their own voice, as well as providing structure and community with other patients. This would “build confidence in the patient which they have often lost throughout the course of their illness … making them feel 'human' again rather than 'a patient'” (P24).

Interactive music making was also thought to impact the patients’ well-being, which would improve their treatment and speed up their recovery. Through allowing patients to be active and have a sense of control, they can feel a sense of achievement and self-worth. In addition, involving motor skills was thought to have a lasting benefit (P4). Therefore, interactive music interventions allow the patient to “[feel] empowered that they can take control of themselves … and anything that encourages active participation is a really good thing” (P2).

Figure 10-12.

Figure 10. Immediate effects of live interactive and performance interventions. Figure 11. Whether music sessions were thought to effect the patients’ recovery. Figure 12. Whether recorded music would be as effective as interacting through live music.

Sixty-three percent of participants thought interactive music interventions would definitely or probably affect recovery with none saying ‘definitely not’ (Fig. 11). Again the most significant theme was the improvement of psychological well-being as this would have an effect on recovery and well-being. Involvement in music making provides patients with the opportunity to express the emotional trauma accompanying illness and for some, preparing for death.

Forty percent of participants thought recorded music was probably as effective as live music, promoting mindfulness (P6) and relaxation (Fig. 12). There would also be a greater control of the standard of music and a wider range of choice. However, 18% of participants thought recorded music would probably not be as effective as live music due to the lower level of engagement (five responses). Therefore, the type of music intervention could depend on the aim of the session, as “if the purpose is for investing in new things and looking for mainly distraction then participative music may provide something more” (P31).

The qualitative data showed three ways recorded music is currently used in a hospital setting. The theme of patient control over the choice of the music, often utilising headphones, was prominent. This was thought to provide familiarity to the patient when in an unfamiliar setting and allow time for reflection. Some participants also referred to the use of recorded music played over speakers. Whilst some participants had had positive experiences of this intervention, others felt the range of tastes among patients was too varied. Two participants mentioned the role of hospital radios and the ability this has to give patients a voice.

A common theme across responses was the importance of maintaining the individual care hospitals aim to provide. It was thought that music would be more effective with certain illnesses and the aim of the session would depend on the patient and their mood at that time. Therefore, for some patients, recorded music might be more appropriate, with the choice of music giving a sense of control to the patient, whilst for others engaging creatively could be of more benefit. The needs of the individual must be considered and the appropriate intervention provided when introducing music.

The Future of Music in Hospitals

Figure 13-17.

Figure 13. Whether respondents would welcome more live music on the ward. Figure 14. Where it would be practical to introduce live music in the hospital. Figure 15. Relationship between agreeing to have a music therapist on the team and welcoming more live music. Having a music therapist on the team was transformed to a metrical variable through creating means, with 7 as strongly agree and 0 as strongly disagree, X² (25, N = 28) = 48.95, p <.05. Figure 16. Relationship between welcoming a music therapist on the team and whether music interventions effect the patient’s recovery. Again having a music therapist on the team was transformed to a metrical variable through creating means, with 7 as strongly agree and 0 as strongly disagree X² (15, N = 27) = 29.16, p <.05. Figure 17. How participants felt a musician or music therapist should be funded.

Evaluation and Implications for Future Research

Establishing generalisability can be difficult in qualitative research, especially in a small study where limited data can be analysed. To allow for a larger sample a mixed methods approach was used creating quantitative data alongside open questions. Utilising online surveys as well as interviews increased the sample size as it required less time and effort from the participant. In addition, the majority of the participants were currently working in one of two hospitals – York Teaching Hospital and Great Ormond Street Hospital. As York Teaching Hospital is a general acute hospital whilst Great Ormond Street specialises in paediatric healthcare, the participants were working with a variety of clients. Participants were also working in various roles and on differing wards which will increase the generalisability of the results to hospitals with differing medical specialities and patient types. The main hospitals included also provide variety as any music provision in York Teaching Hospital was provided through voluntary organisations while Great Ormond Street has funded music therapy. As these hospitals are situated in different geographical locations in the UK, and all of the participants had also worked in other hospitals around the UK, the results can be generalised to hospitals in the UK. However, the data is not representative of the music provision in hospitals outside of the UK.

Another issue is sample bias, due to the busy schedule of the target population only those with a prior interest in music or alternative intervention are likely to respond. Whilst this cannot be avoided, the use of purposive sampling ensured a range of job roles, hospitals and levels of experience were included, making the results as representative as possible. Therefore, the results cannot be generalised due to the small sample, the resources available, and possibly biased interest of the participants. However, purposive sampling and a mixed methods approach made the study more representative.

Structured interviews improved reliability with all participants receiving the same stimuli read from a script which limited interviewer bias. The inclusion of fixed choice answers also increased reliability removing the influence of the researcher in the analysis. Standardised statistical analysis of the quantitative data made the results replicable. Low inference descriptors, such as recording and transcribing interviews reduced the effect of the researcher (Silverman, 2014). The research process and analysis of the qualitative data has been clearly outlined in the methods, allowing for external scrutiny (Silverman, 2014). In addition, quotes were frequently used in the results ensuring that the respondents’ opinions were accurately relayed. In the semi-structured follow-up interview, prompts were used to restrict the interviewer so new topics were only introduced by the interviewee. However, inter-rater reliability was not tested, and therefore researcher bias could have influenced the results.

The main factors undermining the validity of explorative research are the influence of the researcher’s views and the veracity of the respondent’s account. At the time of data collection, the researcher was an undergraduate music student at the University of York. The researcher’s personal belief that music, in particular music therapy, can have great positive benefits in healthcare could have influenced their interpretation of the data. The triangulation of the research, incorporating different forms of data, increased validity as it is “necessary to uncover information and perspective, increase corroboration of the data, and render less biased and more accurate conclusions” (Reams & Twale, 2008 p.133). Analytic induction of qualitative data reduced the influence of the researcher, as hypotheses were thoroughly tested throughout all responses. It was ensured that there was a comprehensive analysis of data and tabulations were created to show the frequency of answers (Silverman, 2014). This increased the validity of the conclusions and allowed the reader to judge them for themselves.

It was accepted that cultural influences would affect the responses, and so results could only be true to the answers given. Having lived in both London and York, the researcher had a similar cultural background to the participants in the study. On the other hand, the researcher has had very little medical training and has little experience working in the hospital setting. Structured and semi-structured interviews were used to minimise the influence of the interviewer which reduces social desirability bias. These methods were used to ensure that the results were as true to what the healthcare professionals thought as possible.

This study raises many questions, due to its explorative nature, and future research holds exciting prospects for the introduction of more music in hospitals. As the culture, gender, and age of the participants was not recorded in this study, it would be interesting in future research to explore whether these factors influence healthcare professionals’ attitudes to music in healthcare settings. Ways in which musicians and healthcare professionals can collaborate effectively need to be defined. The effects of this on the awareness of healthcare professionals and how this alters perceptions should be monitored whilst also outlining practical applications for musicians. A future study could also look further into which disciplines could use recorded music effectively and which could benefit from using musicians. The effectiveness of the different interventions should be explored and the longevity of these effects. In addition, it would be valuable to research differences between hospitals as well as the attitudes of people in different jobs.