Christine Naguib, MTA
There is no doubt that the ongoing pandemic has brought many challenges and changes for everyone, but it has been an especially stressful and challenging time for healthcare providers working in long-term care, long-term care residents and their family members. In June 2020, I got a unique opportunity to experience these challenges firsthand when I got offered a full-time position at a long-term care home that greatly needed support. Before receiving this offer, I was like many music therapists striving to convert my contracts to online and searching for creative ways to reach my clients virtually. I was offered a position within the recreation team, but as an accredited music therapist, I was hired with the agreement that I would use my skills and knowledge as a music therapist to support the residents. Thus, I gained perspective on the reality of life in long-term care during the pandemic.
In addition to my music therapist/recreation role, like many working in long-term care (LTC), I had to assume some additional non-traditional roles. For me, this meant supporting during mealtimes and conducting family virtual video visits. Music therapy at first seemed almost impossible to adapt into the many stresses and demands happening in long-term care. However, I realized that by relying on my training and skills, music therapy can be adapted into an incredibly powerful source of support not only for residents, but LTC staff and family members as well.
The Problem of Long-Term Care and Music Therapy Challenges
LTC has long faced multiple challenges: chronic short staffing, abuse of residents and workers, stressful work environment, and high levels of burnout and turnover. The pandemic has only added more stressors to an already burdened system. Before the pandemic, most music therapists were contracted to several LTC homes for either several hours or for several specific private clients to see. Music therapy services in many institutions were reduced or suspended at various times during the pandemic as they were not considered essential, while staffing for basic care needs became increasingly strained due to more restrictions and hygienic measures being put in place. However, in light of high levels of isolation, anxiety, depression, and reductions in family visits and other activities, music therapy services seemed more essential than ever. Sadly, despite the well-known benefits of music therapy, the lack of funding, as well as other strains, have made it challenging for residents in LTC to access music therapy during the pandemic. And many therapists suddenly found themselves thrust into new or unfamiliar roles in order to support nursing staff and residents in meeting immediate basic care needs.
The pandemic has had a tremendous effect on all the staff working in LTC. With added work, constant changes, outbreaks, short-staffing, pressures, and few breaks, staff have struggled to balance their workload and their health. Caregiver burnout in LTC is not new; according to Mansfield et al. (2016), the burden on caregivers of people with dementia is among the highest of all caregiving groups. Furthermore, caregiving often results in psychological distress such as anxiety, grief, anger, irritability, insomnia and loss of energy (Särkämö, et al., 2014; Särkämö et al., 2012; Ridder, 2017; Osman, & Hanser, Butterfield-Whitcomb, & Collins, 2011.
Adaptations and Successes: innovating to meet an unpredictable environment
Music therapists have certainly not been spared the extra challenges. Due to the constant change and uncertainty caused by the coronavirus, conducting music therapy in person and online requires constant adaptation, flexibility and creativity. At my workplace, group sizes have been reduced to 4 or 5 people, requiring more frequent, smaller groups and more individual sessions. Keeping residents with dementia properly distanced from myself and from one another represents another difficulty, as residents often try to come near. Furthermore, due to the social nature of music, it is hard to avoid “congregating” in music therapy groups. Singing interventions have also been a controversial topic throughout the pandemic, but in my experience singing with PPE and keeping distance from residents has been acceptable. However, it has been challenging to project and sing for longer periods while wearing full PPE and a mask.
The issue of “cohorting,” or treating individuals across multiple units, represents another challenge. When I started working in the summer, I had groups and individuals in every area of the home. Unfortunately, due to restrictions during outbreaks, I had to stay on one unit for long periods of time, interrupting music therapy treatment in other units. Despite these disruptions, I did find that the therapeutic rapport was still there when I returned to my clients on the other units, since luckily during the summer months there were few outbreaks, so I had developed a strong rapport with all the residents beforehand. The uncertainty and constant changes in protocol made it challenging to create a consistent schedule and regularity in treatment, and I found myself questioning if what I was doing still had the same therapeutic effect. I eventually found the answer: consistency and regularity were not the main goals, but rather making sure everything I did had a therapeutic intent in the moment. I had to keep in mind that every individual and group session could be the last, and thus create goals that were shorter term in nature, always figuring out what the goal could be for right now, depending on circumstances. Therefore flexibility, creativity and adaptability were at the forefront.
Along with my music groups, I had also taken on the role to set up and facilitate family video calls for residents during the pandemic. I took this as an opportunity to experiment doing music with family members on video. Often times, I would share what the resident is doing in music therapy with the family and then allow the family members to watch their loved one sing a song or play an instrument. This allowed the family members to also engage in music over video call and to see their loved ones smile and engage. For more non-verbal residents, music has been very effective in providing a means of meaningful communication during video calls, making a significant difference for many of the residents and their families. One family member shared:
“The video calls were a challenge for my Mom as she was not used to them. Whenever there was music as a part of the call, Mom would stay on the call longer and it was a wonderful experience for me at home to watch her sing. When you are not there with them, you do worry about how they are doing. After getting off a video call when you have watched them sing…it certainly helps to reduce some of the worry.”
Music as environment: uniting and inspiring residents and staff
Performing roles unrelated to music therapy, such as conducting family calls, while working alongside nurses and personal support workers (PSWs) gave me insight, empathy, and understanding regarding the stressors experienced by other staff. It also gave me a special chance to use music in some creative and innovative ways to help staff morale, ease environmental tension, and help family members connect with their loved ones over Zoom. I noticed a significant impact when I played pre-recorded music during mealtimes. During the pandemic, mealtimes have been increasingly stressful: in-room dining increases isolation for residents as well as workload and stress for staff within an already demanding schedule. Playing different genres of music incorporating both resident and staff preferences has eased tension and creating a more enjoyable mealtime experience for all. In addition, calm New Age piano music has been helpful in reducing stress. Many staff and residents have provided positive comments on music being provided during mealtimes. As research confirms, when music can be heard throughout the long-term care home, a more positive environment is created for all (Pavlicevic et al., 2015).
I also learned to work around measures requiring residents to remain confined in their own rooms, and when groups were not allowed. Adding further challenge, I was required to wear full personal protective equipment (PPE), including a gown and gloves, to enter a resident’s room when under droplet precautions. In order to adapt, I experimented with a hallway music “group” in which I would set up my music in the hall and the residents would participate from within the entrance of their room. It was challenging to engage the residents in this manner at first, but with the help of enthusiastic PSW and nursing staff, it has been effective in not only engaging the residents in music, but also engaging PSW and nursing staff with the residents. I found it useful to do a mix of familiar songs on guitar, which allowed me to move around more easily and make eye contact with the residents, with receptive piano interventions, when residents engaged with by singing along or playing a percussion instrument in their room. In addition, using pre-recorded music allowed me to help physically engage with the residents from the hall, and it has been effective when doing music and movement interventions.
However, these ‘hallway interventions’ do not come without challenges. There are a lot of interruptions and distractions: call bell alarms going off, medication and housekeeping carts passing by, and PSWs going back and forth and into resident rooms. Although it has been challenging to adapt to these less-than-ideal circumstances, I have come to realize that when music is in the hall, everyone is benefitting. The housekeepers smile, the nurse dances and sings along, and the PSWs grab the maracas and help engage residents. Residents who hadn’t yet participated in the music therapy groups came out just to hear the music. Many care staff had expressed that they get no opportunities to spend quality time with the residents because they are constantly rushed from task to task. However, when I start my music groups, I see that staff naturally start interacting with the residents throughout their busy day by trying to engage with the residents in music, singing to them, and even dancing with them.
Furthermore, the music in the environment had encouraged staff to use music themselves with the residents. For example, a nurse on the unit sang along in harmony while doing her medication passes, bringing smiles to the residents, some of whom commented on her lovely voice, creating a new forum of connection. Even if it were a few minutes, these interactions in the moment mattered for both the residents and the staff. Having the staff engage in the music process has been an essential part of making the hallway groups work, as it also motivates residents. I noticed something magical was happening: the music was bringing everyone together, despite everyone being physically distant and having different roles to play. This experience illustrates the ability of music therapy to create a positive ripple effect on all those involved in resident care.
Osman, S. E., Tischler, V., & Schneider, J. (2016). ‘Singing for the brain’: A qualitative study exploring the health and well-being benefits of singing for people with dementia and their carers. Dementia: The International Journal of Social Research and Practice, 15(6), 1326-1339. doi:10.1177/1471301214556291
Hanser, S. B., Butterfield-Whitcomb, J., Kawata, M., & Collins, B. E. (2011). Home-based music strategies with individuals who have dementia and their family caregivers. Journal of Music Therapy, 48(1), 2-27. doi:10.1093/jmt/48.1.2
Mansfield, E., Boyes, A. W., Bryant, J., & Sanson‐Fisher, R. (2017). Quantifying the unmet needs of caregivers of people with dementia: A critical review of the quality of measures. International Journal of Geriatric Psychiatry, 32(3), 274-287. doi:10.1002/gps.4642
Ridder, M.H. (2017). Partners in care: A psychosocial approach to music therapy and dementia. In S. L. Jacobsen (Ed.) Music therapy with families: Therapeutic approached and theoretical perspectives. Jessica Kingsley Publishers: London.
Särkämö, T., Laitinen, S., Tervaniemi, M., Numminen, A., Kurki, M., & Rantanen, P. (2012). Music, emotion, and dementia: Insight from neuroscientific and clinical research. Music and Medicine, 4(3), 153-162. doi:10.1177/1943862112445323
Särkämö, T., Tervaniemi, M., Laitinen, S., Numminen, A., Kurki, M., Johnson, J. K., & Rantanen, P. (2014). Cognitive, emotional, and social benefits of regular musical activities in early dementia: Randomized controlled study. The Gerontologist, 54(4), 634-650. doi:10.1093/geront/gnt100