Design, setting and participants: During the Christmas season 2008, the Peter Mac Staff Christmas Choir gave seven performances at the Centre. Locations included inpatient wards, outpatient waiting areas and a cafeteria. To assess their response to the choir, oncology inpatients, outpatients and visitors (including early-departing bystanders) were given anonymous, semi-structured questionnaires during and after performances. To analyse the responses, we used a constructivist research approach informed by grounded theory.
Results: Questionnaires were returned by 111 people. The performances were received favourably by 93.7% of respondents, including nine from Jewish, Hindu or atheist backgrounds. Many said the music aroused positive emotions and memories. Several described transformative thoughts and physical reactions, felt affirmed by the Christmas spirit or message, and/or appreciated the peaceful or enlivened and social atmosphere. The choir also elicited personal perspectives about Christmas and Judaism, and the importance of “enjoying the moment”. Only three respondents (2.7%) reported adverse effects, relating to emotional and audible intrusiveness.
Conclusions: The Staff Christmas Choir created a supportive and uplifting atmosphere for many oncology patients and their visitors. However, responses from people from non-Christian backgrounds were limited, and further investigation is warranted to extend our understanding of the effect of Christmas music in Australian public health settings.
For thousands of years, music has significantly enhanced health, character and behaviour.1,2 Music was prescribed to treat disorders in ancient Egypt and Greece, and throughout the Middle Ages, Renaissance and Baroque periods.1 Shamanic cultures still use music as part of rituals for maintaining health and supporting the dying and bereaved.2,3
Supported by Florence Nightingale, concerts were performed in London hospitals from 1891 and, by 1925, 15 New York hospitals had adopted the practice.4 After World War I, music therapy — a profession that tailors music techniques to individualised needs — emerged.5
In the present day, and closer to home, Melbourne Symphony Orchestra members have performed at the Royal Children’s Hospital,6 and tertiary music students regularly perform at St Vincent’s Hospital, Melbourne. Choirs in Melbourne and other parts of Australia often perform in hospitals at Christmas.
The Peter MacCallum Cancer Centre (“Peter Mac”) in Melbourne is a public hospital with 94 inpatient beds, outpatient clinics and an outpatient radiotherapy service. Its Staff Christmas Choir has performed annually since 1956. Given the increasing emphasis on addressing supportive care needs in oncology,7,8 we decided to conduct a small research study on the effects of the staff choir on inpatients, outpatients and visitors during the Christmas period in 2008.
All hospital employees and volunteers are eligible to join the choir. Weekly rehearsals commence around October. Just before Christmas, the choir performs in four inpatient wards, two outpatient waiting areas, and the staff cafeteria (Box 1, Box 2).
There were seven performances in 2008, averaging 40 minutes in duration and involving an average of 20 singers and six instrumentalists. The program consisted of 12 items — 10 Christian carols and two songs with Christmas themes, including “The first nowell” (English), “O little one sweet” (German) and “Christmas comes” (Polish).
Data were collected at the time of the performances or within 24 hours afterwards. Patients and visitors who heard a performance were invited to fill out anonymous, semi-structured questionnaires that elicited brief demographic information and their personal responses to the choir. One researcher also made notes on observed reactions of the audience.
Sealed questionnaire returns boxes were placed in outpatient areas. Within 24 hours of a performance, one of the researchers (C C O) returned to inpatient wards with a sealed returns box and offered to transcribe responses for those who couldn’t write.
As many people as possible who heard the performances were invited to fill out a questionnaire. We used both purposive sampling (approaching people as they departed mid-performance) and convenience sampling (approaching those who remained after performances).9 Questionnaires and pens were given out or located in waiting areas.
We used a constructivist (qualitative) research approach (wherein the knowledge gained from interviews with participants is compared and systematically condensed by the researcher), reflecting our belief that people’s interpretations of the world differ according to their backgrounds.10 The design, informed by grounded theory (an inductive approach in which theory is developed from the data, rather than proposing hypotheses and gathering data to test them), was selected because it allows phenomena to be explained through analysing participants’ and researchers’ interpretations.9,11
Patient and visitor responses were transcribed and subjected to comparative thematic analysis,9,11 with software support.12 Initial analysis (by C C O) encompassed three iterative phases: descriptive labels were created to represent text segments, comparable codes were grouped into categories, and comparable categories were grouped into themes.
Qualitative inter-rater reliability13 was assessed: two authors (C J H and E J P) analysed the data and C C O’s original interpretations. Further alterations were made until all researchers agreed with the interpretation of the findings.
One hundred and eleven questionnaires were returned. At least 47% of inpatients responded. The response rate among outpatients and visitors was impossible to calculate, as scores of people moved through the listening areas during performances.
Respondents’ demographic features are summarised in Box 3. Nearly all patients and visitors (104/111 [94%]) expressed positive responses. Observed reactions were mostly favourable, occasionally negligible, and rarely negative. Two people (one visitor and one outpatient) commented about the music’s loudness. Many observers moved towards the choir, while others ignored it. Some sang along, played instruments and joked with the conductor. A few cried with heads bowed.
Many respondents reported feeling energised, uplifted, calmed or at peace. Individual patients said that the choir’s music created a “Christmas spirit”, helped them feel “fitted for heaven”, and “transcended religious boundaries”. Many visitors welcomed the choir’s diversional, personal and social effects, even if they aroused sad memories. The following is a sample of responses relating to this theme:
Made me happy not depressed. Think life is worth it. I’m in tears. (Patient)
Many listeners were transported by the choir to remembered or imagined places, such as Christmas scenes from their childhood. Memories were variously good, comforting, welcome, nostalgic, happy or sad. Four respondents who described sad memories all said they were accompanied by positive experiences.
The music created a bond between strangers. People from non-Christian backgrounds responded positively and did not express offence about the Christian carols. Two respondents born in communist countries were delighted by the choir’s expressive freedom. Some were uplifted by how the choir brought people together.
Being a Jew I was singing Christmas carols . . . I am very proud . . . we Jews give the world Christianity. (Patient)
Four inpatients (3.6%) reported neutral responses, and three outpatients (2.7%) complained that the music was confronting or loud. The religious backgrounds of these respondents were Christian, unstated or “none”. One respondent commented:
Responses were influenced by the choir’s positive attributes, staff identities and the international nature of the carols (which was regarded favourably). Many respondents were grateful and complimentary, although some said that the choir was too loud or too soft.
To our knowledge, this article presents the first research into the appropriateness of religious or cultural practices in an Australian health care space. Our findings indicate an overwhelmingly favourable response to the staff choir from oncology patients and visitors, regardless of whether they were from Christian or non-Christian backgrounds. Their enjoyment, in an environment characterised frequently by “blunt silence”, “gloom” and “struggle” (words quoted from respondents), was striking. While duration of effect was not examined, being able to “enjoy the moment” was regarded as paramount, especially when dealing with uncertainty shrouding cancer treatment or end-of-life care. Even though three respondents found the music emotionally confronting or too loud, two of them recommended that the choir continue for the benefit of others. A staff choir will not appeal to everyone.
The choir’s positive effects on respondents’ emotions, memories and images were comparable with music therapy’s effects in oncology.14 However, adverse experiences of oncology patients to music therapy have not been reported, possibly because music therapists work in therapeutic relationships with willing participants.15 Music alters mood through an extensive network of activated neural regions and connections involving pleasure, arousal, opioid transmission and dopamine production.16 Memory traces of previously heard music and experienced emotions are also involved.16 Witnessing the choir’s “happy” and “warm” performances (words quoted from respondents) may have also triggered mirror neurones.17
Respondents’ sad memories were accompanied by positive feelings. Through offering multiple messages in non-referential ways, music can expand listeners’ ways of thinking and feeling.18 Music’s power is reflected in its capacity to arouse paradoxical states, acknowledging our fears and grief alongside our thanksgiving and hope.19
Limitations of our study were its small size, small proportion of non-Christian respondents, and restriction to a single institution. We examined responses from oncology patients and visitors who heard the choir, were aware of the questionnaire, and were motivated and able to participate. Thus the survey was open to responder bias, the direction of which is unknown.
Christmas is a Christian celebration that is observed in Australia with public holidays. Christmas music (live and recorded) is played in many health care settings at this time. There has been debate in some sectors in Australia about appropriate observation of religious holidays, and religious spaces in some public hospitals are being converted to multi-faith worship areas in acknowledgement of different religious practices.
Future examination of reactions from people with varied religious and ethnic backgrounds would extend our understanding of the effects of Christmas choirs. We would also encourage others to examine the effects of Christmas music (on patients, visitors and staff) in their own health care institutions.
In summary, the Christmas choir music was welcomed by many at Peter Mac and should be encouraged for supporting oncology patients and their visitors in similar facilities. In the words of a January 2009 article in The Age, “Music binds strangers simply because it does not speak to one person. It is the universal become personal”.20
3 Respondents’ demographic features
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