Music in Hospitals: Anatomy of a Process Costanza Preti Institute of Education University of London This dissertation is submitted for the degree of Doctor of Philosophy May 2009 Declaration I declare that this thesis consists entirely of my own work, except where explicitly stated to the contrary. The thesis fits within the prescribed word limit of 100,000 words, excluding the Appendices. CAN 1/41/J' 2 Acknowledgments I would like to thank the following people whose help has been invaluable during the researching and writing of the thesis: Prof. Graham Welch, who has given me advice and immense support throughout my time in London. I thank colleagues and friends at the Institute of Education, in particular Prof Sue Hallam, Dr. Colin Durrant, Dr. Pam Meecham and Dr. loulia Papageorgi, for their insightful comments at different stages of the research; Family and friends, particularly Milena Nuti, Maria Martorana, Joyce Davis, Vanna and Enrico Sartor, and Micheal Downing. I would also like to thank Lucia Benini; the staff from the 'Pain control service' at the Meyer Paediatric Hospital in Florence; the musicians from the Athenaeum Musicale Fiorentino; the musicians from the UK Charity Music in Hospitalr, all the children and parents and hospital staff that participated in the study. This research was funded by a grant from the Economic and Social Research Council, The Wingate Foundation, and by my parents, to whom I am very grateful. 3 Abstract The research engages with the increasing interest in the application of music in community health contexts. Previous research has tended to have a singular focus (such as on the effects of selected music on individual patients in a clinical setting) and to under-represent the role of the musician. Accordingly, the thesis sought to understand the nature, process and impact of live music in a hospital context from the perspectives of each group of stakeholders (musicians, patients, carers, medical staff and administrators). An initial web-based survey of music in hospitals led to a preliminary observational and interview study of eight musicians working in hospitals for a leading UK charity. The emergent data from these two sources was juxtaposed iteratively with related research literatures to explore the perceived reasons for musical intervention in clinical settings and the reported effects on the different groups of participants. The main fieldwork phase was a month-long qualitative study of a group of nine musicians in an Italian paediatric hospital, selected because it was relatively unique in offering a sustained programme of forty-five hours of music each week across the year for its patients. The fieldwork embraced observations of 55 musical interventions with 162 children (totalling 36 hours and 40 minutes) using a specially designed observation schedule, supplemented by video recordings and 68 interviews with members drawn from each participant group (musicians, patients, carers, medical staff and administrators). Subsequent thematic analyses - informed by grounded theory and systematic content analysis using Atlas.ti software - suggest that provision is generally valued by participants and, overall, having a positive impact on patients and hospital environment. Nevertheless, the Italian data suggest that there are also perceived negatives in such multi-faceted provision, related to the choice and variability of repertoire, musicians' relative status, available monitoring and support, and the often stressful nature of the work. Implications for policy and practice are discussed. 4 Contents Declaration 2 Acknowledgments 3 Abstract 4 Contents 5 List of Tables 10 List of Figures 11 Part 1. Setting the research context 13 Chapter 1. Introduction 14 1.1 The context for this research: My personal experience as a 'musician in hospital'. 14 1.2 Research aim, related questions, and chosen methodology 19 1.2.1 What happens when live music occurs in a hospital context? What are the characteristics of an 'effective' musical intervention? 19 1.2.2 What is the value of offering a musical programme in a hospital setting? Who benefits (if at all) from the musical intervention? 22 Chapter 2. Identities and motivations of musicians who play in hospitals: Fieldwork, literature and synthesis 23 2.1 Introduction 23 2.2 Web-based analysis of music in hospitals programmes 24 2.2.1 Analysis of outcomes of music in hospitals programmes 26 (1) Bedside music 26 (2) Regular concerts in common spaces 27 (3) Special music events 28 (4) Artist-in-residence programme 28 2.2.2 The nature of a sample of associations involved in providing music in hospital activities 29 (1) Stated aims 29 (2) Activities offered 30 (3) Selection criteria in the employment of musicians 31 (4) Structure of the training 31 2.3 A case study of the UK-based Music in Hospitals charity and a selection of its musicians 32 2.3.1 The case study data and their collection 34 Interviews 34 5 Observations 34 Documents 35 2.3.2 How case study data were managed and analysed 36 Interviews 36 Observations 36 Documents 36 2.3.3 The outcomes of the case study of the charity and its musicians 37 2.3.3.1 The Charity as a nested case study 37 2.3.3.2 The choice of music: A survival issue 38 2.3.3.3 An ideal musician 39 2.3.3.4 An example of the selection process 41 Applications 41 Auditions 44 2.3.3.5 The musician's perspectives 47 Motivations 48 Philosophies 48 Skills 50 2.4 Discussion and other empirical studies 52 2.4.1 The choice of music 55 2.5 Chapter summary and overall conclusions 57 Part 2. A review of other related literatures 59 Chapter 3. Hospitalization of children and their families: Setting the context for a musical intervention 60 3.1 Introduction 60 3.2 Children's reaction to illness and hospitalization 60 3.2.1 Children's conceptualization of illness in relation to their developmental stages 61 3.2.2 Children's psychological reaction to hospitalization and models of their coping strategies 65 3.3 The dynamic of hospitalization 71 3.3.1 Reaction to hospitalization: Stages of emotional reaction to trauma as perceived by key participants 74 3.4 Chapter summary and overall conclusions 78 Chapter 4. Music and the child as a patient 80 4.1 Introduction 80 4.2 Why do human respond to music? 80 6 4.2.1 Is music a by-product of other cognitive skills? 81 4.2.2 Is music an evolutionary adaptation? 85 (a) Music as a primordial form of language 86 (b) Music promotes social cohesion and social development 87 4.2.3 Early musical communication: Pre-birth and infant stages 90 4.3 Music as a process 95 4.3.1 The effectiveness of music within a therapeutic setting 95 4.4 Chapter summary and overall conclusions 101 Part 3. The Meyer paediatric hospital in Florence 103 Chapter 5. Research design: An illustrative case study 104 5.1 Overall design 104 5.2 Ethical issues 112 5.3 Contextual features 113 5.3.1 The hospital 113 5.3.2 The project: Musica in Ospedale 114 5.3.3 Theoretical underpinnings and aims of the programme 115 5.4 Structure of the fieldwork 117 5.5 Participants in the study 119 5.6 Chapter summary 124 Chapter 6. Musicians playing in the Meyer paediatric hospital 125 6.1 Observations 126 6.1.1 Code of practice (formal and informal) 126 Arriving in the hospital 126 Timetable issues: (a) Flexibility 127 (b) Rotation 128 Changing room 128 Getting ready 129 Entrance in the ward 129 Break times 130 6.1.2 Elements of a typical session 130 Location of musical activities and structure of a typical intervention 130 Little Percussion instruments 139 Repertoire 141 6.1.3 Common musical techniques characterizing the intervention 142 Verbal and non-verbal techniques characterizing the intervention 145 7 Differences between musicians 148 6.2 Interviews 149 6.2.1 Motivations to undertake the work 150 6.2.2 Perceived aims of their work 152 6.2.3 Perceived nature of the work 154 Risk of burnout and related causes 154 The average length of the intervention and its repercussion on the musicians 156 Rotation issues 157 Coping strategies 159 6.2.4 Main features of a musical intervention 160 The role of percussion instruments 160 Singing and the use of musical instruments 161 Planning the intervention 163 Entrance in the ward 164 Different musical techniques in relation to different spaces 165 Shortage of new repertoire 166 6.2.5 Characteristics of a successful intervention 166 Musicians' personal resources 166 Children's previous hospitalization experiences 168 Role of parents 169 Familiar music and musicians' personal musical tastes: Influence on the selection of the repertoire 170 Non verbal interaction 173 6.3 Musicians' physical and psychological perception of working in the hospital 175 6.4 Chapter summary 182 Chapter 7. Musical intervention from a client perspective 184 7.1 Children, their parents and other carers 184 7.1.1 Observations 185 (1) Children interacting directly with the musician 185 (2) The parent(s) acting as facilitator 188 (3) The musician acting as a facilitator 191 7.1.2 Interviews 193 (1) Children responding to 'music in hospital' 194 (2) Children who do not respond to music in hospital 195 7.2 Hospital staff: Nurses and doctors 198 8 7.2.1 Interviews 199 (1)The perceived effectiveness of the musical intervention for the hospitalized children 199 (2) The impact that music had on their work 202 (3) The perceived professionalism of the musicians playing in the hospital 205 7.3 Administrators 208 7.3.1 Interviews 208 (1) The hospital's official vision of the function and role of music in hospitals 209 (2) The profile of an ideal 'musician in hospital' 210 (3) The conceptualization of the 'music in hospital' project according to the association 211 7.4 Chapter summary and overall conclusions 212 (1) The children and their carers 212 (2) The hospital staff 213 (3) The administrators 214 Part 4.