Z_singingthepassage.pdf

Singing the passage: Evaluating volunteer bedside singing in a Palliative Care Unit Chanter le passage Î évaluation de musique offerte par des chanteurs bénévoles au chevet des patients sur une unité de soins palliatifs Kirsten Davis, MTA G, Michael Downing, MD Jan Walker, BScN Abstract This article describes the preliminary evaluation of a volunteer bedside singing service provided to patients and families at the Victoria Hospice inpatient palliative care unit. This mixed-method study was composed of three questionnaires designed to gather feedback from three groups regarding their experiences with the volunteer bedside singing service: patients and/or families, interdisciplinary team members (including physicians, nurses, counsellors, spiritual caregivers, and unit volunteers) and the volunteer Bedside Singers themselves. 94 referrals were made to the Bedside Singers over a 7-week period with 27 patients/family (29%) accepting the offer of singing and of these, 8 (29.6%) completed the survey. Patients had a Palliative Performance Scale score of 30% or less and lived an average of 6.6 days (min 1; max 18 days) before death. Three of the eight surveys returned were completed by patients, with the remainder completed by family members or unit volunteers on the patient's behalf. Patient and family responses to the service were generally very positive, while interdisciplinary team members' responses were more cautious. Possible benefits and detriments of volunteer music support services in palliative care settings are discussed, and further research to compare professional music therapy services with volunteer music support services is strongly recommended. Keywords: music therapy, music, palliative care, hospice, singing, volunteers, qualitative research Canadianjournal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 77

Résumé Cet article décrit l'évaluation préliminaire du service bénévole Bedside Singers (chanteurs au chevet des patients) offert aux patients et aux familles sur l'unité de soins palliatifs du Victoria Hospice. Cette étude mixte est composée de trois questionnaires conçus pour amasser les impressions de trois groupes de personnes soit des patients et/ou leur famille, des membres de l'équipe interdisciplinaire (y compris les médecins, infirmières, conseillers, intervenants spirituels et bénévoles de l'unité) ainsi que les bénévoles mêmes de Bedside Singer, sur leur expérience avec le service Bedside Singers. 94 recommandations de clients ont été transmises à Bedside Singer sur une période de 7 semaines avec 27 patients ou familles qui acceptaient l'offre de services de musique; 8 (29.6 %) ont terminé le sondage. Les patients étaient évalués à 30 % ou moins sur l'Echelle de performance pour patients en soins palliatifs et ont passé une moyenne de 6.6 jours (de 1 à 18 jours) sur l'unité avant leur décès. Trois des huit sondages ont été remplis par des patients tandis que les autres ont été remplis par des membres de leur famille ou des bénévoles de l'unité, au nom du patient. Les réponses du patient et des familles au service Bedside Singers ont été généralement très positives, tandis que celles des membres de l'équipe interdisciplinaire ont été plus prudentes. Les avantages possibles et les préjudices d'un service de soutien musical offert par des bénévoles au sein d'une unité de soins palliatifs sont discutés; il est fortement recommandé d'effectuer des recherches ultérieures afin de comparer un service professionnel de musicothérapie avec un service de soutien musical offert par des bénévoles. Mots clés : musicothérapie, musique, soins palliatifs, hospice, chant, bénévoles, recherche qualitative Introduction The bedside singing service was initiated in 2007 by a community group of volunteer singers called Songs of Passage (SOP), who had a special interest in offering support to seriously ill or dying patients through unaccompanied singing. This approach was adapted from that of the Threshold Choir network in the United States. The all-women Threshold Choirs "provide singing at the bedsides of patients in transition struggling with living or dying" (Munger, 2008). The unaccompanied voice is the only instrument used. Threshold Choir volunteers sing in pairs or small groups for patients in hospices, hospitals, nursing homes, and private homes when invited by family or caregivers. When the family is present, the music is provided for them as much as for the patient, and family members are invited to join in the singing or to listen. Choir members Canadian Journal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 78

may visit once or multiple times depending on the patient's circumstances. The songs used are chosen to respond to a patient's musical taste, spiritual direction, and physical capacity. The Threshold Choir's repertoire includes rounds, chants, lullabies, hymns, spirituals, and choral music (Munger, 2008). The bedside singing group was led by two dedicated volunteers who had extensive experience in choral singing, music education, hospital pastoral care, and hospice palliative care volunteering. Prior to and throughout the pilot project, the bedside singing volunteers (Bedside Singers) received musical training from their leaders through weekly group practices. They also received orientation to the Palliative Care Unit (PCU), and a full-day training seminar provided by PCU staff, familiarizing them with the physical and psychosocial needs of patients and families receiving palliative care. During the pilot project, the volunteer Bedside Singers provided service on the PCU for two hours weekly, in pairs. The Songs of Passage bedside singing service used a range of simple, gentle, lullaby-type repertoire chosen from a broad spectrum of cultures. The songs used were spiritual but not religion-specific (Mary-Moon & Lamb, 2008). A comparison of music therapy and bedside singing interventions and approaches is found in Table 1.

Canadian Journal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 79

MUSIC THERAPY AND BEDSIDE SINGING: AT A GLANCE (NJB. This list provides MHne, but not all, of the differences between the respective roles.) PCU MUSIC THERAP£?T Is an accredited professional witfa minimimi of undogradiiate level training in music therapy and clinical experience in palliative care. Uses famfliar mnak from • wide variety of genres (cfandod, pop, «wred, eonntry...), which is selected based on individual patient's requests, needs and preferences. Provides iive initrnmeiifad or vocal mnfic, «H* treeordcd mnaic on request May use tongwriting techniques to preserve patiraits' memories and emoticHis as original compositions. Wodcs indcpendenfly, taldng referrals from an members of tiie PCU team. Has counselling skills wiiidi allow IKT to nse music in glided life review and/or symptom management teehniqnes with patients. Involves patients/families in the musicmaking expeiieBoe by inviting tiinn to partic^ate in ringing, piaying instruments, eo-writing songs, discasring mnsie sdeetioiu. Con^letes a written assessment of patients* musical preferences, badcground, and responses, '«4iich is added to tiie

BEDSIDE SINGERS Are volunteers trained in small ensemble singing and psychosocial aspects of palliative care. Offer rqwftoiie fiom a prepared repert
Conqilete record of visits to communkate naHnnf rraiinn«r« w l l l i ihlli«r 1IJW1«S«1M

Singnrs and with die music thoqñsL outcomes veibally and in writing to die mtetdisciplinary team on an ongoing basis. * Referrals flow back andfi>ithbetween the Music Thocqiist and Songs of Passage Singers, depoiding on what an individual Hospice patient may need Table 1. Music TherapyA^ohnteer Bedside Singii« Comparison.

The volunteer Bedside Singers offered bedside singing as a pilot project, under the supervision of the Music Therapist, on the PCU from August 2007 to May 2008. The PCU Music Therapist provided education regarding the respective roles of the music therapist and volunteer musicians, acted as a liaison between the Bedside Singers and the unit staff team, provided consultation regarding musical repertoire, provided patient referrals for each bedside singing shift, Canadianjournal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 80

tracked and evaluated all visits documented, and audited random bedside singing visits to ensure appropriateness and quality of the service. The goal of the bedside singing project was to expand the range and accessibility of live music services offered to patients and families by volunteers, particularly during evenings and weekends. The evaluation was intended to gather information regarding patients', families', staffs', and PCU volunteers' responses to the bedside singing service, and to determine if the service was a beneficial adjunct to the music therapy services currently offered. The Hospice program also wished to gather information regarding patients', families', staff's, PCU volunteers', and Bedside Singers' responses to the service, in order to improve its service delivery and volunteer training. Literature Review Throughout history and across cultures, music has been used to facilitate Hfe transitions, particularly birth and death. Music therapy research Hterature demonstrates that the systematic clinical application of music can address the physical, psychosocial, and spiritual needs of patients and families at end of life. For patients, music therapy interventions (including singing, instrument playing, song writing, improvisation, and listening) can be used in conjunction with pharmacological and other approaches to address acute and chronic pain symptoms (Magill-Levreault, 1993; Trauger-Querry 8¿ Haghighi, 1999). In addition, music therapy interventions have been shown to provide opportunities for patients to explore feelings and issues exacerbating the pain experience (Magill, 2001), thus addressing total pain (pain incorporating physical, psychological, social, emotional and spiritual elements) (Downing & Wainwright, 2006). Music therapy can assist patients in coping with disorientation and dementia (Hilliard, 2001), provide a comforting presence (Krout, 2003), and improve quality of remaining life as well as easing of death (West, 1995; Hilliard, 2003). For both patients and family members, music therapy has been demonstrated to positively effect stress levels (Avers, Mathur, & Kamat, 2007), to reduce anxiety (Stillwater-Korns, Malkin, & Puchalski, 2006), and meet spiritual needs by generating hope and transcendence (Salmon, 2001), and by addressing the lack of meaning and hopelessness (Hilliard, 2001). Music therapy can ease communication between patient and family members (Krout, 2003), and provide comfort to those experiencing anticipatory grief (Davenport, 2002). Family members of palliative care patients described witnessing their loved ones' music therapy sessions as a joyful, hopeful, empowering spiritual experience (Magill, 2007). These family members were also able to transcend feelings of distress and remorse, and Canadian Journal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 81

experienced a heightened sense of meaning as they observed the effects of music therapy sessions on the patient. Music therapy research literature also yields findings specifically related to the use of singing and songs in oncology and palliative care which indicates that hospitalized cancer patients listening to live music (voice and guitar) reported significantly less anxiety and more vigour than those listening to recorded music, as well as more changes in physical discomfort and mood (Bailey, 1983). Songs were described as a means of support and a tool for change, which provide a framework for tension release, integration, and pleasure for cancer patients, particularly when song themes emphasize hope, reminiscence, relationships, feelings, loss, death and peace (Bailey, 1984). Familiar songs have personal meaning for patients, which can be used to help patients to acknowledge and explore feelings in the face of loss and death (Magee, 2007). However, there is no research literature examining the use of unaccompanied bedside singing provided by volunteers to patients and families in hospice palliative care. The purpose of this pilot study was to understand the experience of patients and families receiving volunteer bedside singing services, and the effect of volunteer bedside singing as witnessed by the interdisciplinary team. Research Design and Methodology This mixed-method study was composed of three individual questionnaires designed to gather feedback from three groups regarding their experiences with the bedside singing service: patients and/or families, the interdisciplinary team members (including physicians, nurses, counsellors, spiritual caregivers, and PCU volunteers) and the volunteer Bedside Singers. A maximum sample size of 12 patients and/or family members, 12 interdisciplinary team members and 6 Bedside Singers was chosen for this pilot study. The surveys included basic demographic information and a 5-point Likert scale o f - 2 to -1-2 was included for some participants to indicate numerical responses to some of the questions. The patient and family surveys and the bedside singing volunteers' surveys requested some quantitative responses using the Likert scale. The surveys completed by the unit staff and volunteers, surveys consisted of open-ended questions only; no Likert scale was used. The qualitative aspect of the study asked all participants to describe their experiences of the bedside singing service and make suggestions to improve the service. Each survey included open-ended questions about the service Canadianjournal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 82

and was analyzed for themes that elucidated the experience of those receiving or witnessing the service. The small sample size did not warrant the use of qualitative analysis software to encode and group emerging themes, and was done by a research team member. Similar responses were grouped together by key words. Emotional tone and content of responses guided the creation of theme codes. The patient/family survey was completed by the patient (if able), or by a family member/friend present in the room when the singing occurred. The Research Coordinator recorded the patient's functional status using the Palliative Performance Scale [PPS - see Appendix 1] (Anderson, Downing, Hill, Casorso, 8c Letch, 1996; Ho, Lau, Downing, 8c Lesperance, 2008), as well as the amount of time elapsed between the bedside singing visit and the patient's death. Recruitment Process The patients and families were selected to receive an offer of bedside singing services based on a clinical evaluation by the Music Therapist. To ensure patients' and families' safety and satisfaction, the bedside singing service was purposely structured such that it could only operate during the music therapist's work hours, and only with the music therapist's direct, on-site support and guidance. The Music Therapist selected patients with a functional status of PPS 30% or lower (patients who were totally bed bound, unable to do any activity, requiring total care, with normal or reduced food/fluid intake, and fully conscious or drowsy; see Appendix), and/or patients with specific symptoms which might be addressed by application of sedative music (insomnia, restlessness, and/ or pain). Prior to visiting, the Bedside Singers were given a brief summary of information regarding the patients referred to them, including each patient's name, age, diagnosis, PPS score, family members involved, and religious affiliation (if known). The Bedside Singers then approached patients and if the offer of bedside singing was accepted, they provided the service. After the visit was completed, the Research Coordinator met with the patient/family and explained the study, the letter of invitation and the consent form. If they chose to participate, the patient and/or family were given the survey and asked to leave it in a sealed envelope for pickup by the Research Coordinator. A similar invitation letter and survey form was also made available to the PCU staff, PCU volunteers and Bedside Singers. Canadian Journal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 83

Ethics Review This study received approval by the Health Research Ethics and Review Board of the Vancouver Island Health Authority (VIHA Eile H 2008-20) and the Research Committee of Victoria Hospice Society. It is funded in part by an unrestricted grant from the Victoria Foundation. There is no conflict of interest. Results As seen in Table 1,94 referrals were made to the Bedside Singers over a 7-week period with 27 patients/family (29%) accepting the offer of singing and of these, 8 (29.6%) completing the survey. Surveys returned partially completed were included in the final data analysis as there was no expectation or obligation to complete all of the survey; those surveys returned without any responses were discarded. Demographics are summarized in Table 2. Patients received bedside singing an average of 6.6 days (min 1; max 18 days) before death. Tabk 2. BediMe Singer Rcferndf and Survey Data CoDeetùm Procen Category Time period (days) Referrals by Music Therapist Did Not Sing Why Not Sing

Did Sing to Patient/Family Sofveys given out afler siagjng Ifno survey, why survey not given ont?

Surveys Retnmed

ExphBaMoB # J Tuesdays & Wednesdays over 7 weeks

14 94 67

2 1 12 9 10 3 5 20 5

Includes repeats on second day SOP singers would go to room to see if OK 1 died; 1 imminent death Bedside Singers insufficient time Patient asleep Patient busy/treatment Unavailable Visitors present Delirium/inappropriate Refused or postponed Other

Did not sing to 71%

Did sing to 29% SmveystD 37%

27 10 3 3 2 1 3 1 2 2 8

% N/A

Patirait asleep Patient incqiable/coiifiised Aheady done one Singas did not notify lesemdi aasistant ^ o t appropriate' Sang to deceased patioit Semi-cansäoifii NotiBconted 80%rettn3Md

Canadian Journal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 84

Patient and Family Surveys Table 3 outlines all survey questions and tabulated results. Three of the eight patient and family surveys were completed by patients themselves, four were completed by family members, and one was completed by a unit volunteer on the patient's behalf. All eight patients and family members participating rated the experience of receiving bedside singing as +2 on the 5-point Likert scale, or "very positive." Comments included descriptors such as "good", "wonderful" and "most enjoyable" as well as "calming", "soothing", and "uplifting". One respondent described the experience in greater detail, stating that witnessing his mother receiving bedside singing was: "Another cathartic moment. My Mom's appreciation of music runs deep and I sing to her as part of the care I give her. Now, however, at the very end, I find it difficult to do without crying and my crying does upset her so much. This service provides something essential that I am emotionally struggling with doing." Table 3. DemogmpUcs of 8 patients receiving Bedñde singii« Gender F F F M F F F M

Age

PPS*

Survey completed by Patioit

Ttme from visit to Death (days)

18 PPS 40% 79 PaûeOL 4 PPS 40% S3 13 PPS 30% 68 Patioit 1 PPS 10% 82 PPS20% Son 7 94 2 PPS20% 77 7 PPS 30% 71 Daughter 1 PPS 10% 79 6.6 days (mean) 79yrs (mean) • PPS (Pidliative P«fiwinance Scale) see Appendix

Six out of eight patients and family members rated the selections of music used during bedside singing as -1-2 on the 5-point Likert scale, or "very positive". Comments about the music used included "the two selections were appropriate and meaningful" and "a very general selection about peace, something I daily wish for my Mom for the rest of her trip out of life." One out of eight respondents rated the selections of music as -l-l, or "somewhat positive", and one out of eight rated the selections of music as 0, or "neutral". Suggestions for changes to the bedside singing were related to the visibility and accessibility of the service, including that bedside singing be offered "in Canadianjournal of Music Therapy <» Revue canadienne de musicothérapie, 17(1), 85

the evening" and "not at lunch/meal time," and that "...a poster be placed in the patients' lounge about (the bedside singing) service." Four of the eight respondents stated they would not suggest any changes. Interdisciplinary Team Member Surveys Six interdisciplinary team members returned surveys [two registered nurses, one licensed practical nurse, one physician, and one social worker, one anonymous]. Three out of six team members reported positive observations of the bedside singing visits, stating the service was "very well received from patients, wanted singers to come again, very calming and soothing", that it was "lovely to hear them", and commenting that the singers were "very gentle and sensitive to patients' wishes". Two people had no comment while one team member observed that the Bedside Singers' "energy often feels/seems awkward...they have not integrated smoothly into the team." Two out of six team members stated they had received strongly positive feedback from patients and families regarding the bedside singing service, and reported comments such as "They (Bedside Singers) are wonderful" and "What a great thing to offer," while one staff member had received somewhat positive feedback from patients and families regarding the bedside singing service. Three out of six team members stated they had not received any feedback from patients and families regarding the bedside singing service. When asked to suggest changes or improvements to the bedside singing service, two staff requested that Bedside Singers directly solicit nursing staff members' input into their service. One suggested, "Get nursing input of doing a visit or the timing of the visit." Another observed, "I don't know if the [Bedside Singing] team is shy, but I don't see them engaging with nursing staff" One team member requested an increase in the level of bedside singing services available, but another team member commented, "I feel that the Bedside Singers detract from, rather than enrich the [Music Therapist's] role." When asked if bedside singing should be continued as a regular service on the PCU, five out of six team members responded "yes". One respondent commented, "I would like to see them engage with all the team and include nursing." Another responded "no", stating that the bedside singing volunteers "crowd the place because they're often [on the PCU] at the same time as the PCU counsellor, spiritual care providers, and Music Therapist."

Canadian Journal of Music Iherapy oo Revue canadienne de musicothérapie, 17(1), 86

Unit Volunteer Surveys A total of 4 PCU volunteers were surveyed using the same questionnaire completed by the interdisciplinary team members. Three out of four PCU volunteers reported indirect positive observations of the bedside singing visits, stating the singing sounded "beautiful, peaceful and spiritual" and "friendly, peaceful and loving at all times." Two out of four PCU volunteers stated they had received direct positive feedback from patients and families regarding the bedside singing service. One volunteer commented, "I received comments from anyone who heard it, including patients, families, staff, volunteers, visitors. I believe it touched the soul of anyone who was within hearing distance." The other two PCU volunteers surveyed stated they had not received any feedback regarding the service. The only change suggested by the PCU volunteers was to increase the frequency of the bedside singing service. This one respondent suggested, "Perhaps have them available more often." Three out of four PCU volunteers responded "yes" when asked if bedside singing should be continued as a regular service. One commented, "I think this service really fits in hospice." One respondent did not indicate "yes" or "no." Bedside Singing Volunteer Surveys As seen in Table 3, all 6 Bedside Singers (including the two volunteer group leaders) returned their surveys and rated their experience of providing bedside singing as -t-2 on the 5-point Likert scale, or "very positive." One commented "I love it" and another singer described a sense of purpose and contribution through her experience: "It is a privilege to belong to this group of singers, and an honour to provide songs of love and healing to patients. When I leave the [PCU] I feel I am making a difference, however small." All 6 Bedside Singers also stated they felt "very welcome" (-1-2 on the 5-point Likert scale) and supported by the staff and volunteers on the PCU. One Bedside Singer described the PCU staff and volunteers as "always very friendly and helpful."

Canadianjournal of Music Therapy oo Revue canadienne de musicorhérapie, 17(1), 87

Table 4. Snrwy Qnettioii Ttlralatioii. Granp

Qacition

Ukert Scale

-2

-1

0

+1

+2

Very negative to very positive P8tieals& Families

UnitlnterDiadplinaiy Staff

Unit Volnntoets

Wbat was the Q^KiieDce of receiving Bedside Singing like fi>ryon7 How did you £»1 about flie selections of music (songs) used for Bedside Singing? Aie Ifaetc any change« or inçrovemeols that you would Suggest for Bedside Singing visits in general, or fiir this visit in paitieiilai? Did yoo observe or hear any Bedside Singing visits {novided to patients andfirmiliesin your can? Ifso, «lut were your observations of die Bedside Singing service? Did you receive any feedback fiom patients or ämiliesiegardiiig the Bedside Singing service? If so, what were their commente? Are Üiere any dianges or inqwDvonents that you would suggest for the Bedside Singing semce? Do youfiselthat Bedside Singing should be continued as a regular sovice for [PCU] iiQMdienls and äieir fimulies? Did you observe or hear any Bedside Singing visits provided to patients and ämilies in your care? Ifso, «4iat were your oberavations of die Bedside Singing service? Did you receive any feedback fiom patiente or âmiliesngarding the Bedside Singing service? If so, vriiat were their commente? Aie diere any dianges or inqirovements diat you would suggestfi>rthe Bedside Singing service? Do you feel that Bedside Singing should be continued as a legular service fix [PCU] iiqmtiente and Üieir fiunüies?

0

0

0

0

8

1

1

6

+1

+2

Yes No

4 4

Positive Negative No

3 1 2

Positive Negative No Yes No

3 1 2 5 1

Yes No

5 1

Yes No

3 0

Yes No

2 2

Yes No

1 2

Yes No response

3 1

-2

0

-1

Veiy negative, unwelcome or unprepared (-2) to veiy positive (+2) Bedside Singers

What was die experience of providing Bedside 0 0 0 0 Sin0]%Uke for jrou? Did you feel welcomed ft suppm led bytitostaff and volunteers on dw [PCU]? IMd you feel adequately trained, equipped and 2 ^«¿ired to offor Bedside Singing? Ale diQiB any wuuigesOTluipiovuuiente diBt you 7 suggestions made would suggest for ¿ e Bedside Singing service? Table 4. Survey Question Tabulation. Poor distinct surveys w o e distributed aid aie noted in die lefi column.

6 6 4

Four out of the six Bedside Singers surveyed responded that they felt "very prepared" to offer bedside singing on the PCU (+2 on the 5-point Likert scale), while the remaining two out of six stated they felt "somewhat prepared" (+1 on the 5-point Likert scale). Two offered additional comments regarding their Canadian Journal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 88

experiential learning process, stating,".. I am learning as I go along." and".. .1 am very aware of how we are continuously adding to our training program from our hands-on experience..." Changes or improvements suggested by the Bedside Singers included increased access to patient information, and additional or alternate bedside singing shift times (late afternoon and evening), and changes to the duration of preparatory activities during bedside singing shifts. Discussion The Music Therapist selected patients with a PPS of 30% or lower to receive bedside singing for this study. These patients were selected for three reasons. First, at this functional level, these patients are closer to death and thus have limited time to benefit from music interventions. This would decrease the likelihood that Bedside Singers would offer long-term or in-depth support to patients and families, but would rather provide a short-term service. Second, these patients' compromised physical strength, energy and mobility might render them less able to participate (than patients with a higher PPS) in active music therapy interventions such as instrument playing. Finally, as patients' verbal communication abilities are often limited at this PPS, it might be easier for them to passively receive bedside singing rather than reminiscing, singing, or discussing musical preferences and song requests in the context of a music therapy session. However, the study selection criteria likely decreased the amount of data gathered since patients receiving the Bedside Singing service were often unable to accept or decline the service unless a family member was present to speak on their behalf, and were often too weak or confused to complete the survey. While this study has been useful for our palliative program, results may not be generalizable. They pertain only to the experience of these three groups of participants and the small sample size obviates full statistical analysis. The results are also limited by the lack of specific criteria for a "successful visit" beyond patient and/or family satisfaction (i.e. symptoms relieved or reduced in severity). While patients' and family members' responses are particularly positive, it is unclear whether the effects/benefits of bedside singing as described by family members are for themselves or the patient. These positive responses could also indicate that patients and families receiving care in a PCU are 'open' to many kinds of support, including music, and therefore may be vulnerable to receiving services which may not be appropriate for or of benefit Canadian Journal of Music Therapy <» Revue canadienne de musicothérapie, 17(1), 89

to them. Recipients of the bedside singing service expressed appreciation, and there was no apparent harm caused by bedside singing. However, there may be a potential detriment to the music therapy profession, as it is imperative, but also difficult for the music therapist to provide appropriate referrals and adequate supervision for bedside singing volunteers. Although the bedside singing service was purposely structured such that it could not function without the music therapist's supervision and support, this duty proved more timeconsuming than expected. Additionally, it became clear during the project that the music therapist's involvement could not eventually be phased out as was originally hoped. Teaching and supervising these volunteers can easily consume an inordinate amount of the music therapist's already small number of work hours on the PCU. It is difficult to evaluate whether or not this expenditure of time is justifiable, given the outcomes reported by this pilot study. Additionally, the music therapist could experience decreased job satisfaction if s/he were to provide more volunteer supervision and less direct patient care, a change not intended nor appropriate given the professional value of the therapist role. As might be expected, the Bedside Singers themselves were very positive about the service, whereas interdisciplinary team respondents were somewhat more cautious in their responses. Team members' responses may or may not reflect the differences between professional music therapy interventions and a volunteer service. PCU staff may have had higher expectations of the volunteer bedside singing service, having had opportunities to be educated by the Music Therapist regarding professional music therapy interventions. This difference is also highlighted by the fact that the PCU volunteers' survey responses were more positive overall than the PCU staff's. It is difficult to assess the feedback from team members, given the very small number of respondents. However, it appears that further integration of the Bedside Singers with the PCU team, particularly through increased communication and coordination with nurses, could increase the effectiveness of the service. Overall, however, the efficacy, safety, and efficiency of the volunteer bedside singing service remain unclear. Survey results also reflect the practical realities of offering music on a Palliative Care Unit (PCU), where there are many competing demands on patients' and families' time and energy; meals, visitors, nursing care, spiritual care and counselling support, as well as the need for rest. It is often difficult to find a convenient and appropriate time for patients/families to receive live music, even though it may be recognized as being of benefit to them. It was interesting to note that, in this regard, the challenges experienced by the Bedside Singers Canadianjournal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 90

match those experienced by the PCU Music Therapist (such as the timing of singing in the context of nursing care). Likewise, many of the suggestions offered for improving bedside singing (such as increasing visibility, frequency, and timing of the service) could likely also be applied to optimizing music therapy services on the PCU. Interestingly, several of the potential weaknesses of the volunteer bedside singing service suggested in the survey responses matched those suggested by Nissim, Regehr, Rozmovits, 8¿ Rodin (2009), who stated that the potential weaknesses of their psychosocial volunteer service were: (1) a limited awareness by patients of the volunteers' roles and responsibilities; and (2) the lack of a structured volunteer role definition. Conclusion Based on the pilot survey outcomes, we conclude that volunteer bedside singing support appears to be of some value but this service needs further detailed study. In view of the recent increase in alternative music support providers (music thanatologists, music practitioners) in the health care field, literature is needed to outline the differences between professional music therapy interventions and music support offered by volunteers or other service providers. Therefore, a larger, comparative study addressing the quantitative and qualitative differences between the effects of music therapy and other types of music support, including volunteer bedside singing, is recommended. There is a place for different types of music-related interventions in a palliative care setting, however, the role and scope of each needs to be further clarified and articulated. This study has been beneficial in providing feedback regarding the existing volunteer bedside singing service. As a direct result of the study, several changes to the service have already been implemented, including rescheduled bedside singing shift times, decreased musical repertoire and increased signage on the PCU regarding the service. The need for ongoing professional music therapy direction to the volunteer bedside singing service has been confirmed in our program, with the result that this service is provided in a more focused way to specific patient groups. As this long-term volunteer supervision consumes several hours per week, the music therapist has now been allotted additional hours for direct patient care.

Canadian Journal of Music Therapy <=<> Revue canadienne de musicothérapie, 17(1), 91

Acknowledgements Many thanks to Wendy Wainwright, Manager of Psychosocial Services, and Brigitte McKenzie, Manager of Volunteer Services at Victoria Hospice, for their support of this innovative project. Thanks also to Marnie Lamb and Pashta Mary Moon, Songs of Passage group leaders, and all the bedside singing volunteers, for their gifts of song at the Victoria Hospice PCU. Palliative Performaiue Scak ^PSv2) PPS Levri PPS 100% PPS 90% PPS 80% PPS 70% PPS 60% PPS 50% PPS 40% PPS 30% PPS 20% PPS 10%

Nomial activit)r & woric Full No evidence of disease Nonnal activity & woifc Full Sane evideoce of disease Nonnal activity & waA. with ettaA Ml Some evidence of disease Unable normal Redoced activity &woik Significant disease Unable bobby/bouse Reduced woik Significant disease Unable to do any Mainly sit/lie work Extensive disease Unable to do nxist Mainly in bed activity Extoisive disease Unable to do any TotaUybed activity bound Extensive disease Unable to do say TotaUybed activity booad Extensive disease Unable to do any TotaUybed activity bound Extensive disease

^^^^^^ PuU

Normal

FuU

FuU

Nonnal

Full

FuU

Normal or reduced

FnU

FuU

Nom^or reduced

FuU

Occasimial assistamx

Nonnal or reduced

FuU or confiision

Consideiable Normal or assistance reduced

FnU or drowsy orccnfiisioa

Mainly assistance

Normal or reduced

FuU w drowsy

Total caie

Reduced

FuU or drowsy +/-canfiisiaa

Tc^cate

Minimal sips

FuU or drowsy +/-confusion

Total car«

Mouth care Dfowsyor cmly coma

PPS Dead 0% Initmctkmi: PPS level is detemÙDed byreadingleft to riglit tofinda'best hcnizontal fit' Begin at lefi column leading downwaids nntil cutrent ambnktion is detemnned, then, read aooss to next and downwatds tmtil eaeh eohnnn is detecmiDed. Thus, 'leftward' colanuis take precedence over 'rigbtwaid' cohmms. Abo, see 'definitions of trams located at www.vietoriahospice.oig. Appendix 1. PaUiative Pecfimrmnce Scale (PPSv2). G Victoria Hospice S o c i ^ (used with pomission)

Canadianjournal of Music Therapy oo Revue canadienne de musicothérapie, 17(1), 92

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12(1), 5-11. Avers, L., Mathur, A., & Kamat, D. (2007). Music therapy in pediatrics. Clinical Pediatrics, 46(7), 575-579. Bailey, L. M. (1983). The effects of live music versus tape-recorded music on hospitalized cancer patients. Music Therapy, 3(1), 17-28. Bailey, L. M. (1984). The use of songs in music therapy with cancer patients and their families. Music Therapy, 4(1), 5-17. Davenport, D. S. (2002). Singing mother home: A psychologist's journey through anticipatory grief Dentón, TX, US: University of North Texas Press. Downing, G.M and Wainwright, W. (Eds). (2006). Medical Care of the Dying, (4* ed.). Victoria, BC: Victoria Hospice Society Hilliard, R. E. (2001). The use of music therapy in meeting the multidimensional needs of hospice patients and families. JoMrwi)/ of Palliative Care, 17(3), 161-166. Hilliard, R. E. (2003). The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer, fournal ofMusic Therapy, 40(2), 113-137. Ho, F., Lau, E, Downing, G. M., ÔC Lesperance, M. (2008). Reliability and validity of the Palliative Performance Scale (PPS). BMC Palliative Care, 7(10). Krout, R. E. (2003). Music therapy with imminently dying hospice patients and their families: Facilitating release near the time of death. American fournal of Hospice & Palliative Care, 20(2), 129-133. Magee, W. L. (2007). A comparison between the use of songs and improvisation in music therapy with adults living with acquired and chronic illness. Australian fournal ofMusic Therapy, 18,20-38. Magill-Levreault, L. (1993). Music therapy in pain and symptom management. Jowrna/ of Palliative Care, 9(4), 42-48. Magill, L. (2001). The use of music therapy to address the suffering in advanced cancer pzin. fournal of Palliative Care, 17(3), 167-172. Magill, L. (2007). The spiritual meaning of music therapy after the death of a loved one: A qualitative study of surviving caregivers. ProQuest Information &• Learning, US.

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Mary-Moon, P., & Lamb, M. (2008, July). Songs of Passage. Retrieved January 21, 2010 from http://victoria.tc.ca/Health/SoP/; http://www. songsofpassage.com/ Munger, K. (2008). Threshold Choir, from http://www.thresholdchoir.org/ how.htm Nissim, R., Regehr, M., Rozmovits, L., 8c Rodin, G. (2009). Transforming the experience of cancer care: a qualitative study of a hospital-based volunteer psychosocial support service. Support Care Cancer, 17(7), 801-809. Salmon, D. (2001). Music therapy as psychospiritual process in palliative care. fournal of Palliative Care, 17(3), 142-146. Stillwater-Korns, M., Malkin, G., & Puchalski, C. M. (2006). The role of music at the end of life. In A Time for Listening and Caring: Spirituality and the care of the chronically ill and dying, (pp. 319-330). New York, NY, US: Oxford University Press. Trauger-Querry, B., & Haghighi, K. R. (1999). Balancing the focus: Art and music therapy for pain control and symptom management in hospice care. Hospice fournal, 14(1), 25-38. West, T. M. (1995). Psychological issues in hospice music therapy: Errata. Music Therapy Perspectives, 13(1), 55-55.

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