Visual Aid Use in Hospital Music Practice  |  Wendy Lanxner

Music has been used for centuries in cultures throughout the world to aid in healing (Sonke, 2011). Musicians working in the hospital setting, sometimes called music for health practitioners (Livesly et al., 2016), music in health practitioners (DeBúrca, 2014), musicians in residence, or music specialists (Perkins et al., 2018), are a part of the currently expanding field of arts in health. Their work differs from the work of music therapists in that there is no diagnosis or clinical treatment plan. Instead, they provide an enjoyable musical experience to a patient with the primary goals of promoting healing, providing distraction, reducing suffering, and normalizing the hospital setting (Sonke, Rollins, Brandman & Graham-Pole, 2009). Music practitioners create a safe space in which musical interactions can occur (Preti & Welch, 2012), sometimes involving caregivers and staff. They can humanize the hospital environment, providing relief from the pain, lack of control, anxiety and stress associated with hospital stays (Bouteloup, 2010).  

These goals remain consistent in hospital music programs. However, a broad range of styles, activities, and approaches are used. Some practitioners solely perform bedside and in common spaces, while others engage patients in more interactive musical experiences. 

Active Music-Making & Patient-Preferred Repertoire

While music listening can have a significant impact on health and well-being and is widely used in hospitals around the world (Fancourt & Finn, 2019; Hetland, Lindquist & Chlan, 2015; Sorensen, 2015, Zyromski, 2020), active music participation has been shown in numerous studies to have a stronger effect (Longhi & Pickett, 2008; Longhi, Pickett & Hargreaves, 2015; Preti & Welch 2011, Rabeyron et al., 2020). Live music sessions generate an increase in oxygen saturation levels, which promotes growth and well-being (Longhi & Pickett, 2008), and can lead to reduced levels of stress hormones and improved immune system response (Kuhn, 2002). Daisy Fancourt et al. (2016) carried out a study in order to assess the impact of singing on mood, stress and immune response in three populations affected by cancer: caregivers, bereaved caregivers and patients. In all participant groups, singing was associated with significant improvements in health biomarkers. 

Using patient-preferred music is strongly recommended for a variety of reasons.  The use of familiar songs supports the goal of normalizing the hospital environment  (Silverman, Letwin & Nuehring, 2016), and choosing a familiar song gives patients an increased sense of agency (Livesly et al., 2016). Patient-preferred live music has been shown to provide comfort & relaxation, ameliorate anxiety, boredom and loss of control; and provide a human connection (Selle & Silverman, 2019). Patients may experience positive feelings of recognition, discovery and accomplishment when they are able to join in on a familiar song. In order to facilitate such experiences, support materials such as chord charts, lyric sheets, or other visual aids may be used when helpful. 

Benefits of Visual Aid Use

The use of visual aids in hospital music practice is in alignment with research supporting their widespread use in many settings (Gardner, 1983; Güney, Rao & Gagie, 2019; Hodgdon, 2000). Visual aids can contribute to cross-modal learning, as they can assist in understanding other sensory input. In their article on the use of visual supports for children with autism, Rao and Gagie enumerate several reasons for using visual aids: they are part of everyone’s communication system; they can attract and hold attention, they enable focus and can reduce anxiety; and they make abstract concepts more concrete (2006). Musician and patient can jointly focus on a visual aid, diverting attention away from self, thereby potentially reducing anxiety. Reading lyrics to a familiar song can be comforting; and a chord diagram can help a patient who wants to try playing a ukulele have a successful experience. In these and other ways, visual aids can often enhance a musical experience in the hospital setting.

Alternative Music Notation

Bedside music interactions are usually quite brief - there is no time for anyone to learn how to read music notation. However, creative non-traditional notation, symbols, or color-coding can be helpful in some cases. In Zimele-Steina’s survey of piano teachers for their recommendations on ideal teaching aids for young players; visual attractiveness was mentioned frequently by teachers of beginners ages 5-7 (2015).  Vilde and Medne found that visual aids support musical memory development, essential for all musical activity (2014). other research also indicates that children prefer color-coded music notation and find it easier to play (Rogers, 1991).  All of these studies point the way towards the potential benefits of using easily accessible, colorful visual aids to facilitate musical experiences in the hospital setting. 

The effectiveness of this type of visual aid is exemplified by a testimonial regarding a color-coded ukulele songbook created by William Dawson, musician in residence at Duke University Hospital. This practitioner observed that a non-musician patient can learn quickly and easily with this visual aid: “I have seen how children in the hospital light up as they realize they are actually playing the ukulele…. this is one way that children can be happy and feel a sense of success while hospitalized” (Dawson, 2018). 

Healing Benefits of Musical Learning 

It is important to note that educational outcomes of hospital music-making, although not the primary goal of such activities, can provide additional benefits to patient well-being. Musical activities promote brain development and benefit related skills of reading, sound-processing, and speech (Fancourt & Finn, 2019). Clinical studies have confirmed that an injured brain can be rewired through active musical learning (Sorensen, 2015). Music-making can provide positive modeling for caregivers (Livesly et al., 2016) and social stimulation, enhancing connections among  patients, caregivers and staff.

Not only do musical activities engage cognitive skills such as concentration, memory and coordination, but they can provide a vehicle for empowerment and confidence, enhancing learning potential (Preti & Welch, 2004; Shin, 2011). Evidence has shown that musical activities promote brain development and benefit related skills of reading, sound-processing, and speech (Fancourt & Finn, 2019), stimulating "neurogenesis and neuroplasticity” (Sorensen, 2015, p.3). In their controlled experiment using musical rhythms as cues for motor control with stroke patients, Thaut and Rice found that speed, stride length and muscle development factors showed dramatically better results for the group receiving the rhythmic auditory stimulation (1997). These studies and others provide ample evidence of the healing power of music learning. 

Normalizing the Hospital Environment 

Hospital music interactions often take the form of a musical game, providing distraction in the form of a non-medical activity that is enjoyable, intellectually engaging (Preti & Welch, 2011), and normalizing. In their study of music interventions in a hospital in Salford, U.K., Livesly et al. (2016) found that musical interactions helped to alleviate the boredom of lengthy hospital stays: 

It makes me feel more ‘normal’. It gives me pleasure to watch my son enjoy quality time…
- A parent (p.42) 

Children like Lewis can miss a lot of normal experiences like music, and he really enjoys it…
- Play specialist (p.43) 

Musical interventions in pediatrics address "the part of the child that is not sick... the part that wants to live and grow," says Didier Cohen-Salmon (n.d.), director of the French non-profit Musique et Santé.  Music in health practice serves the whole child and brings a sense of normalcy to the stress and anxiety often present in a hospital stay.

Visual aids are but one tool of the music practitioner, who must be equipped with a healthy dose of musicality, flexibility, sensitivity, playfulness, and positivity. It will be interesting to see how the emerging field of hospital music practice develops over time, and the way different approaches evolve and grow.


Preliminary Research Study

Visual aids are commonly used in music therapy, but their use by  music practitioners is thus far undocumented. This researcher carried out a preliminary study geared toward exploring visual aid use, focusing on the frequency of their use, the nature of their design, and their perceived effectivenesss.   

This survey study had a total of 44 respondents, 38 of whom indicated they were professionals and 4 of whom indicated they were volunteers (two did not indicate). Most respondents (n=33) were age 50 and above, and most were female (n=32).  Of all the respondents, a fairly small percentage (23% ) indicated that they use visual aids. Lyric sheets were the most commonly used visual aid, followed by chord diagrams and music notation. Others cited by respondents were facial expressions, a list of tunes with starting notes, and unspecified communication aids.           

Question 7, a series of Likert scale questions regarding visual aid use which was the main section of the questionnaire, received only 8 responses.  All but one respondent felt that visual aids were helpful to some degree, and all indicated that they use color-coded stickers in some way in their practice.. Five used visual aids fairly regularly, and six said patients responded positively to visual aids. More than half (5) said they had to create their own visual aids to suit their needs.   

The scope of this study was limited by the lack of existence of a national directory of music practitioners; the pool of participants was developed through internet research. Twenty-nine out of forty-four respondents indicated that they were Certified Music Practitioners (CMP), who do not engage in interactive music, but rather provide “live acoustic music at bedside, one-on-one, for therapeutic purposes...addressing a patient’s immediate needs to provide a healing environment” (What is a Certified Music Practitioner, n.d.). Given the performance-based work of CMPs, this high percentage likely skewed the results, under-representing interactive practice.