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1 Section 1: Programme Structure and Artistic Interventions
External Evaluation Report 2020Marion Friend MBE, Gráinne Hope, Charlotte Wells
Edited by Conni Rosewarne
2 Contents
ContentsIntroduction 4
Context 6
RoyalBrompton&HarefieldNHSFoundationTrust 6
RoseWard&PaediatricIntensiveCareUnit 6
Foulis,Rowan&FirTreeWardsandtheTransitiontoAdultServices 6
rb&hArts 6
VocalBeats 7
StaffandRolesWithintheProgramme 8
TimelineofVocalBeats 9
Methodologies 11
Section 1: Programme Structure and Artistic Interventions 13
ContractualAgreements 14
ProfessionalDevelopment 15
MusiciansinHealthcareMentoring Programme 16
YouthVoice 17
MusicalProgression 19
TheProfileofVocalBeats 20
Section 2: The Artists’ Perspective 21
ProfessionalMusiciansinHealthcareandTheirRole 22
Relationships 24
ArtistSupport 25
Section 3: Clinical Perspective 26
WhyAnalysethisInterventionfromaClinicalPerspective? 27
HowMighttheInterventionWork? 27
ReviewofClinicians’ExperiencesofSingingProjectsWithinHealthcare 29
DynamicPhysicalityofSingingSessions 30
PracticalFocusonBreath 30
3 Contents
Non-threateningtotheMedicalParadigm 30
ScientificEvidence 31
CollaborationWork 31
Conclusion with Recommendations for rb&hArts and Other ‘Music in Hospitals’ Programmes 33
SummaryofRecommendationsfromtheThreeSectionsofthisEvaluation 35
Additional Information Resources 37
Further Reading 37
Bibliography 38
Arts: 39
Clinical: 39
ACKNOWLEDGEMENTS 41
APPENDIX: Description of Conditions 43
CysticFibrosis 44
Bronchiectasis 44
Asthma 44
PrimaryCiliaryDyskinesia 44
Post-CardiothoracicSurgery 45
Front cover photograph © Elam Forrester
Vocal Beats logo by Bethinn Evans
Report design by Gem Davis
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IntroductionConni Rosewarne, rb&hArts Music Programme Manager
Whenconsideringourparticipatorymusic-makingprojectVocalBeats,itisfascinatingtoreflectonitsdevelopmentoverthepast5yearsandwhathasbeenpossibleinthattime.Priortotheintroductionofthisinitiative,whilerb&hArtswasdeliveringadynamicprogrammeforadultpatients,activitiesspecificallyforyoungpeoplewerelimited–andgrowingevidencebothexternallyandinternallysuggestedthatweweremissingacrucialopportunity.Theprogrammestartedwithasinglemusiciansinginglullabiesoneafternoonaweekandhasgrownorganicallythroughcollaborationacrossartistic,organisationalandclinicalareas;itisnowdeliveringtwoafternoonsofmusicactivityperweekwithsinging,beatboxingandukuleleonoffer.Inadditiontothis,1-to-1vocalcoachingsessionsarenowofferedtoyoungpeoplegoingthroughtheoften-challengingtransitionphasetoadultservicesoncysticfibrosisandtransplantwards,alongwithaYouTubechannelco-producedbyYouthAmbassadorsandonlinemusic-makingcoursesinthewakeoftheCovid-19pandemic.Thishasallbeengreatlysupportedbyfantasticpartnershipsandadvocacywithinthetrust,includingthepaediatricplayteam,andrespiratoryphysiotherapistswhobridgeaccesstopatientsandprovideadeeperunderstandingoftheirexperiencesandneeds.InthepastyearwedevelopedakeypartnershipwithTheRoyalMarsdenNHSFoundationTrust,deliveringmusicsessionstoyoungcancerpatients,and havebeenshortlistedfortwoprestigiousawards.
5 Introduction
Gettingtothisstagehasnotbeenwithoutitschallenges.ThoughwehavebeenincrediblyluckytobesupportedbyYouthMusic,CoopBuildingConnectionsFund,TheBromptonFountainandBBCChildreninNeed,sustainablelong-termfundingcontinuestobeaconcerninthecurrentclimate.Intermsofprogrammedelivery,findingtheprofessionalmusiciansrequired–withexceptionalpersonalandmusicalskillsincludingadiverseandadaptablerepertoire–fortheever-changingcontextsofhospitalwardscanbetrickytomaintainonaweeklybasis.Inadditiontothis,wehavehadtoovercomeseveralbarriersinordertoreacholderyoungpeopleonadultwards,particularlythosewithcysticfibrosis–suchisthenatureofworkingwithintheparameterssetbyaneeds-ledpractice.Allinall,theprojectrequiresrobustinfrastructurelestitbecomestoodelicateabalancetomanage.Thishasbeencompoundedinrecentmonthswithservicesunabletocontinueonhospitalwardsthrough-outthepandemic,meaningmusicianshavehadtoquicklyadapttoonlinedeliverytoserveyoungpatientsconsidered‘extremelyvulnerable’andrequiredtoshield,withlimitedsocialopportunitiesoraccesstoeducationalservices.
Theseachievementsandchallengesareexploredinthisreportbymeansofthreedistinctvoiceswhichrepresentartsorganisations,artists’workinglivesandclinicalperspectives,witheachwell-respectedandhighlyregardedintheirrespectivefields.ThisoverarchingevaluationbringstogetherthreereportsbyMarionFriendMBE,GráinneHopeandCharlotteWellstopresentanexternalexpertbird’s-eyeviewoftheprogramme,via
independentreviewandanalysisfromtriangulatedperspectives.Thisevaluationapproachreflectsthechallengethatartistsfaceinembodyingacomplexinterdisciplinaryroleandpracticeinhealthcareandseekstodemonstratehowtheseinterdependenciescancometogethertorunaneffectiveprogramme.WehopethattherecommendationsthatarisefromappraisingthepracticeofVocalBeatsinthisway,givenattheendofthisreport,canofferpracticalsolutionstoissuesoftenmetinmusicinhealthcare,whilstalsoidentifyingspecificimprovementstostrengthentheVocalBeatsprogrammeforthelongterm.WhilstthisreportwasconceivedpriortotheuncharteredterritoryofCovid-19,itstillprovidesacrucialdialogueonhowmusicinhospitalscanbestserveyoungpatientswhichispertinentaswebegintobroachatentativereintroductiontoward-basedworkinthecomingmonths.
Likewise,wehopeotherNHSTrustsandacutesettingswillbeinspiredtoshareinourjourneyandgainadeeperunderstandingofwhatcanbepossiblewhendevelopingthistypeofworkforpatients.Weaimtoadvocateforasocialmodelofhealth,applauding‘softeroutcomes’thatcanhaveahugeimpactonapatient’sjourneythroughthehealthcaresystem.
Finally,thisreportcelebratesthemassiveachievementsmadebyourmusiciansandeveryonewhohastakenpartinVocalBeatssinceitsinceptionin2015.WelookforwardtothenextfiveyearsofVocalBeatsandwillbereportingthedevelopmentoftheprogrammeinanotherexternalevaluationin2025.
6 Context
ContextRoyal Brompton & Harefield NHS Foundation TrustRoyalBrompton&HarefieldNHSFoundationTrustistheUK’slargestspecialistcentreforthetreatmentofheartandlungdisease.Workingfromtwosites–RoyalBromptonHospitalinChelsea,London,andHarefieldHospitalnearUxbridge–theTrustisinternationallyrenownedfortheexpertiseofitsstaff,highstandardofcareandresearchsuccess.ExpertsattheTrustprovidesomeofthemostcomplexsurgeryandsophisticatedtreatmentsavailableanywhereintheworld,topatientsfromall agegroupswhohaveheartandlungconditions.
Rose Ward & Paediatric Intensive Care UnitThepaediatricdepartment,RoseWard,isanationalheartandlungreferralcentreforchildren,offeringafullrangeofdiagnosticandsurgicalinterventionsforpatientsfromprenatalto16yearsold.Hospitalisedchildrenfaceamyriadofcomplexchallengeswhichcanbefurtheraffectedbyprolongedand/orrecurrentstaysinahospital.
TheTrust’sPlayServicesupportspatientsandtheirfamiliesduringtheirstay.Itaimstoensurethateveryyoungpersonhasthebestpossiblehospitalexperienceandispreparedfortheirclinicalintervention,offeringarangeoffunandsocialactivitiesintheplayroomandatthebedside.Inaddition,theChelseaCommunityHospitalSchoolprovidesNationalCurriculumeducationforallyoungpeopleattheTrust.
Foulis, Rowan & Fir Tree Wards and the Transition to Adult ServicesFoulisWardislocatedatRoyalBromptonHospitalinChelsea,andspecialisesincareforcystic
fibrosis.TheTransplantUnit(RowanandFirTreeWards)isbasedatHarefieldHospital,oneofsevencardiothoracictransplantcentresacrosstheUK.Careattheunitincludesassessmentfortransplantationofpatientsonthewaitinglist,aswellasassessmentfollowingtransplantationforreadmissionsandforpatientswhoarefittedwitha leftventricularassistdevice(LVAD).
Atallthreewardscarebeginsfromage16,withthetransitionforpatientsfrompaediatricservicescarefullymanagedbyinterdisciplinaryteams.Thistransitioncanbechallengingforyoungpatientsandtheirfamilies,especiallyastheymayhavebeencaredforbythesamepaediatricteamformanyyears.Researchhasshownthattransitionprocessescanhaveadverseeffectsonyoungpeople’smentalhealthandwellbeingiftheappropriatelevelofcareandsupportisnotoffered,andthetrusthasdevelopedspecialisttransitionpathwaystoensurethiscanbedoneascomfortablyaspossible.
rb&hArtsrb&hArtsisdeliveredthroughRoyalBrompton& HarefieldHospitalsCharitywith3.6(FTE)staffmembers.Itischaritablyfundedtobringthebenefitsoftheartstosupportinpatientsandoutpatientsandthelocalcommunitiessurroundingeachhospital.Theartsprogrammeaimstoincreaselevelsofwellbeing,enhancethepatientexperienceandimprovethehealthcareestatethroughthearts.Itbeganin2002,andinatypicalyearnoworganisesmorethan500interventionsacrossarts,music,andparticipatoryarts,workingwith30artistsandrecordingover6,500participants.Thecorecreativeprogrammeincludes3weeklySingingforBreathingworkshopsforolderpeoplelivingwithchronicobstructivepulmonarydisease(COPD);
7 Context
2 MusiciansinResidenceproviding6hoursoflivemusicforadultsperweek;temporaryexhibitions;and‘crafternoons’whichoffer10hoursofparticipatoryartsandcraftsworkshopspermonth.
Vocal BeatsVocalBeatsisahospital-ward-basedmusicprojectforchildrenandyoungpeopleaged0-25yearsoldatRoyalBrompton&HarefieldNHSFoundationTrust.Theweeklyprogrammeincludes:
• Twoafternoonsessionsofsinging,ukuleleandbeatboxingforchildrenaged0-16yearsonRoseWardandthePaediatricIntensiveCareUnit(PICU);
• Oneeveningsessionofvocalcoachingforyoungadultinpatientswithcysticfibrosis(CF)onFoulisWard;
• Oneafternoonsessionofvocalcoachingforyoungadultinpatientsawaitingorrecoveringfromcardiothoracictransplant.
Thesesessionsrangefromperformancesforbabiesandtoddlersto1-to-1teachingsessionsforteenagers.Eachsessionistailoredtotheneedsofthepatient:whethertohelpwithrelaxation,offeranexperience,ordistractfromdiscomfort,withactivedynamicsingingorbeatboxingsessions.Performance-basedsessionsforyoungerchildrenaretailoredtoincludethechildren’sfavouritesongs,aswellastoencourageeyecontactandparticipationbymeansofactionsorclapping,movementanddancing.Thesingingandbeatboxingsessionsareindividuallytailoredtoeachchild,andalongsidethemainsingingorbeatboxteachingactivitytheyincludeanactivewarm-upforbodyandvoice,posturalawarenessandrealignment,diaphragmaticbreathingawarenessandpractice,andvocalexercises.
Theprojectcurrentlydeliversover900hoursofparticipatorymusicperyear.Itaimstoincreaselevelsofmentalwellbeingbyfacilitatingaccesstohigh-qualitymusic-makingopportunitiesforyoungpeopleandtheirfamilies,whilstalsodevelopingmusicskillsandenhancingthepatientexperience.
Figure 1 Heather McClelland leading instrumental group
sessions © Nik Read
8 Context
Staff Member Job Title Role description
Karen Taylor
InterimPatient&Public EngagementProgrammeManager& ArtsLead
StrategicleadforArtsattheTrust.FormerlyHeadofArts.
Karen Janody InterimHeadofArtsOverseesandmanagesrb&hArtsprogrammedeliveryandfundraising.
Conni RosewarneMusicProgrammeManager,formally ProjectCoordinator
ProjectmanagementofVocalBeatsandMusiciansinHealthcareMentoringProgramme.Leadforevaluation.
Heather McClellandLeadMusicianinResidence
Overseeingward-basedmusicactivitieswithcriticalinput.Deliveringsingingandukulelesessionsforpatientsaged0-16onRoseWardand1-to-1vocalcoachingforcysticfibrosispatientsaged17-25.
Stac Dowdeswell MusicianinResidenceMaternitycoverforsingingandukulelesessionsforpatientsaged0-16.Nowdelivering1-to-1vocalcoachingfortransplantpatientsaged17-25.
Bellatrix BeatboxerinResidenceDeliveringbeatboxperformanceandfacilitationfor patientsaged0-16.
MC Zani BeatboxerinResidenceDeliveringbeatboxperformanceandfacilitationfor patientsaged0-16.
Staff and Roles Within the Programme
9 Context
Timeline of Vocal BeatsAneedforlivemusicinpaediatricwardswasidentifiedfollowingthepublicationoftheBi-Annual Children and Young People’s Survey(CareQualityCommission,2016),whichhighlightedthatyounginpatientsfelttheydidnothaveenoughcreativeactivitiesoropportunitiesforengagementwhilestayinginhospital.Simultaneously,agrowingbodyofevidenceindicatedsignificantbenefitsfromaccesstolivemusicinhealthcareforyoungpatients–particularlywithregardto mentalandphysicalwellbeing,relaxation,anddistraction.
2015ThankstoinitialfundingfromhospitalcharityTheBromptonFountain,HeatherMcClellandwasrecruitedintopostasMusicianinResidencedeliveringbedsidesingingandukulelelessonsoneafternoonaweekonRoseWard.Thisworkwassuccessful,mostnotablywithyoungerpatientsandtheirfamilies,howevertherewasademonstrablegapinengagementwithteenageboys.McClellanddevelopedgoodrelationshipswithclinicalstaffinthisinitialstage,includingphysiotherapistCharlotteWellswhohadpreviouslysupportedandadvocatedformusiciansonSingingforLungHealthprojects.TogetherMcClellandandWellsbegandiscussingandsharingresourcesforwaysthatvocalexercisescouldpotentiallysupporthealthoutcomesinrespiratorypatients,particularlythosewithCF.ThebookThis is a Voice (Kayesetal.,2016)becameapivotaltext,inspiringtheideaofusingbeatboxingasawaytoaddresstheidentifiedgapinengagementwhilstalsopromotingfurtherlunghealth.ArelationshipwiththeUKUkuleleKidsClubwasalsodeveloped,anditbegantosupplyukulelesforyoungpeopletokeepafterdischargefromhospital.
2016rb&hArtssuccessfullyappliedtotheYouthMusiccharityforFundAsupporttoexpandtheprojecttotwodaysaweek,forprovisionledbyMcClellandandwithprofessionalbeatboxersonbothdays.
10 Context
2017YouthMusicandTheBromptonFountaincontinuedtofundVocalBeats,withrb&hArtssuccessfullyapplyingtoBBCChildreninNeedtocreateapart-timeProjectAssistantposttosupporteffectiveevaluationoftheproject.rb&hArtshostedtheannualNationalAllianceofMusiciansinHealthcare(NAMIH)conferenceatRoyalBromptonHospital,organisedbyOPUSMusicCIC.
2018YouthMusicincreasedfundingtotheproject.ThissupportedtheexpansionofprovisiontoincludeyoungadultswithCFtransitioningfrompaediatrictoadultcareandyoungadulttransplantpatients,aswellasgoingtowardsthedevelopmentandstart-upoftherb&hArtsMusiciansinHealthcareMentoringProgramme.Menteeswererecruitedwithamusician-ledinductionday.VocalBeatsmusiciansdeliveredpresentationsatSoundConnectionsEarlyYearsandNAMIHconferences.Ashared-practicedaywasheldbyrb&hArts,hostingmusicians,Singing for Lung Healthpractitioners,musictherapistsandrespiratoryphysiotherapistsforachancetoshareknowledgeanddevelopnetworksacrosstheUK.
2019 5menteescompletedthementoringprogrammeandpublishedreflectiveessaysontheYouthMusicNetwork.CharlotteWellsledtrainingsessionsfor VocalBeatsmusiciansinrespiratoryhealth.rb&hArtssuccessfullyappliedto YouthMusicFundBtobegindeliveringadditionalmusicsessionsforyoungcancerpatientsaged0-25atTheRoyalMarsdenNHSFoundationTrust,commencinginSeptember.VocalBeatswasregisteredasaserviceevaluationatRoyalBrompton&HarefieldNHSFoundationTrusttoformaliseevaluation,gatheringpublishableevidencetobeconcludedin2021.TheprojectwasshortlistedfortheYouthMusicSocialActionAwardandtheRoyalSocietyof PublicHealth’sArtsinHealthAward.
11 Methodologies
MethodologiesThisreportismadeupofstandaloneassessmentsbythreeexternalevaluatorswithdifferentspecialisms.Thisapproachseekstocreateamulti-facetedoverviewoftheprojectfromkeyperspectivesthatareseparatebutinterlinked,tohighlighttheproject’ssuccessesandpotentialsandtoprovidelearningsforbothrb&hArtsandforthewider‘musicinhospitals’sector.ThecommissioningbriefforthereportwasinformedbytheYouthMusicDo, Review, Improve2017qualityframework,whichisatoolthatmusicpractitionersandorganisationscanusetosupportplanning,reflectionandevaluation.
Allthreeevaluatorsappliedqualitativemethodstogeneratethinking,feedbackandrecommendationsforthefutureoftheVocalBeatsprojectaswellasforother‘musicinhospitals’programmesthatmaybelookingtoreplicatesimilarmodelsofpractice.ThereviewlooksatpracticedeliveredatRoyalBrompton&HarefieldNHSFoundationTrustonly,anddoesnotincludesessionsbeingdeliveredatRoyalMarsdenNHSFoundationTrustasthesearestillintheirinfancy.
MarionFriendMBEhasheldseniorpositionsinprestigiousinternationalculturalorganisationsforovertwenty-fiveyears,includingDirectorofJuniorTrinityatTrinityLabanConservatoireofMusicandDance,andpostsatWigmoreHall,BBCTelevisionMusicandArts,andthePhilharmoniaOrchestra.Marionnowworksasacoach,mentor,facilitatorandconsultant.HerreviewexaminesVocalBeats’organisationalstructureandcapacityforprogression,focussingonlearninganddevelopmentoutcomesforparticipantsandmusicleaders.
Friend’smethodologyincludes:
• Individualface-to-faceinterviewswiththeteamoffourprofessionalmusiciansandwithonementeeparticipatingintheMusiciansinHealthcareMentoringProgramme
• In-personandtelephoneinterviewswithConniRosewarne,ProjectCo-ordinator
• TelephoneinterviewswithJenniferRaven,DeputyDirectorSoundConnectionsandwithCarolineMooreArtsManager,GreatOrmondStreetHospital
• ObservationoffoursessionsinRoseWardandFoulisWard,RoyalBromptonHospital
• AttendanceatRowanWardHarefieldHospital
• Informalconversationswithpatients,parentsandcarersduringobservations(permissionstatusgranted)
• Deskandpodcastresearch
• Drawingonrelevantexperienceincludingattendanceand1-to-1coachingatSoundConnectionsEarlyYears/ArtsHealthandWellbeingConferenceFebruary2018
Gráinne HopeisaprofessionalcellistandthefounderandArtisticDirectorofKids’Classics,whichdeliversamusicprogrammeinIreland’schildren’shospitals.ShewaschosentorepresentIrelandtobecomeatrainerofMusiciansinHealthcareSettingsaspartofapioneeringEuropeanprogrammeledbyMusiqueetSanté(France).Her evaluationofVocalBeatsisfromanartistpeer reviewperspective.
12 Methodologies
Gráinne’ssectionofthereviewappliesaqualitativeapproachtothemethodology,whichincludesinformalinterviewsandafocusgroupwiththreeVocalBeatsmusicians,aswellasobservedvisitsinHarefieldHospitalandonRoseWardatRoyalBromptonHospital.
Topicguidesfortheinterviewandfocusgroupsweredevelopedfromresearch,personalexperiencedevelopingprogrammepartnerships,managingandtrainingprofessionalmusiciansworkinginhealthcaresettings,andwithreferencetotheEngaged Passions, Searches for Quality in Community ContextspublicationbyrespectedresearcherandwriterPeterRenshaw.Questionswerekeptopen-endedtoallowparticipantstooffermoredetails,personalinsightsandknowledge.
Charlotte WellsisaHighlyspecialistrespiratoryphysiotherapistwithoverfifteenyears’experiencespecialisinginrespiratoryservicesincludingcysticfibrosis,bronchiectasis,emphysema,primaryciliarydyskinesiaandasthma,aswellasworkingwithinsleepandventilationteams.Sheiscurrentlyinpostasaspecialistpaediatricrespiratoryphysiotherapistworkingwithinatertiaryservicemanagingchildrenwithdifficult-to-controlasthmaandexercise-inducedlaryngealobstruction(e-ILO)atRoyalBromptonHospital.
CharlottehasjustcompletedherNIHRMastersinClinicalResearch.Priortobeingappointedforthisreport,CharlottecontributedtotheVocalBeatsprogrammebyeducatingmusiciansonrespiratoryconditionsandworkingwiththemtodevelopvocalfacilitationtechniquesthatcomplementrespiratoryphysiotherapy.Shehasauniqueperspectiveintermsofpaediatricrespiratoryconditionsandtheaccompanyingclinicalandsocialcontexts,whichmakesherinputtothistriangulatedevaluationinvaluable.
Charlotte’ssectionreviewspublishedliteraturetobetterunderstandhowmusic,singingandbeatboxingcouldbebeneficialforcardio-respiratoryhealth;sheofferscommentaryonclinicians’experiencesofhospital-basedsingingprogrammes(Singing for Lung Health);andexploresthepotentialbenefitsofcollaborativesessionsbetweenVocalBeatsandthephysiotherapyteam.
Thedatafromallthreereportsisincorporatedin an overallconclusionwithdiscussionofinterlinkingthemesattheendofthisdocument.Thisisaccompaniedbyasetofrecommendationstobeusedbyrb&hArtsandotherprofessionalindividualsandorganisationsdeliveringmusicin healthcareprogrammes.
13
Section 1: Programme Structure and Artistic InterventionsMarion Friend MBE
TheweeklymusicalactivitywithintheVocalBeatsprogramme isdevelopmental,asmanypatientsreturnregularlyforspecialisttreatmentandsomearethereon a longer-termbasis.
Theprogramme’ssuccessispredicatedonasmallteamofhugelydedicatedprofessionalmusicians.Excellentrelationshipshavebeenbuilt;themusicianshaveidentifiedpotentialandsupportedparticipantsindevelopingtheirmusicianship,oftenwithgratifyingoutcomes.
Throughdemonstrablyproductiveandmutuallysupportiveworkingrelationshipswithclinicians,theplayteamsandrb&hArtsmanagement,themusicianshavefoundtheirplaceatthe‘heart’ofthehospital.Anunderstandinghasdeveloped;theyhaveassimilatedintothecultureofanacuteclinicalenvironmentandareconstantlylearninghowtheirmusicalinterventionscandovetail,interlinkandenhancethepatients’emotionalandphysicaldevelopmentandprogression.
14 Section 1: Programme Structure and Artistic Interventions
There’s a constant dialogue between performers, play team and clinicians. It’s very holistic. It’s integrated and you get to know everyone well and build relationships, for example with Charlotte Wells, physiotherapist. So music isn’t separate from the overall experience. The hospital has a close relationship with the arts, and music’s presence is natural. Feedback from the team is welcome and ideas are nurtured.Heather McClelland
TheVocalBeatsprogrammedemandsskilledcommitmentandconvictionfromthesmallcohortofprofessionalmusiciansinvolved,allofwhomhaveactivelivesasperformersintheUKandoverseas.Sensibly,thepolicyistohaveonesingerandonebeatboxerineachsession,whichmeansthatcontinuitycanbemaintainedevenifoneperformerhastoputinadeputyonoccasion.Thatsaid,itcanbechallengingtofindasuitabledeputywiththeskills,experienceandsensitivityforthespecialisthospitalenvironmentatRoyal
Brompton&Harefield.Onesolutionhasbeentheintroductionof theMusiciansinHealthcareMentoringProgrammedeliveredbyrb&hArtsandSoundConnections,asdiscussedlater.
Managementofthewide-rangingandinnovativeartsprogrammeatRoyalBrompton&HarefieldNHSFoundationTrustisundertakenbyasmallteamledbyKarenJanody,HeadofArts,withstrategicoverviewfromKarenTaylor,Patient&PublicEngagementProgrammeManager&ArtsLead,previouslyHeadofArtslaunchingVocalBeatsin2015.Theteamishugelycommittedbutatcapacitygiventhestrategic,fundraisingandoperationalfunctionsrequiredtorunitsrangeofactivitiesencompassingvisualart,craft,commissions,exhibitionsandthepioneeringSinging for Breathingweeklyworkshopsforadultswhicharenowcelebratingtheirtenthanniversary.
ThemainregularpointofcontactfortheprofessionalmusiciansontheVocalBeatsprogrammeistherb&hArtsProjectCo-ordinator.Thisjobtitlemaynotadequatelycommunicateto thoseoutsidethedepartmenttheextentoftheresponsibilitiesinthisrole(sinceupdatedto‘MusicProgrammeManager’).TheyincludeactingasanintermediarybetweenthemusiciansandRoyalBrompton&HarefieldNHSFoundationTrust;communicatingtothewiderstaffcommunity;supportingtheunderstandingoftheworkanditsroleinthetrust;andundertakingresearchandevaluationinliaisonwiththemusicians.RecentevaluationworkincludesthecomprehensiveVocal Beats Year 2 End of Year report 2018-19,andtheProjectCo-ordinatoriscurrentlyinvolvedina serviceevaluationfortheprogrammewhichwill continueuntil2021.
Contractual AgreementsThefourprofessionalmusicianswhodelivertheVocalBeatsprogrammeareemployedonafreelancesessionbasis,withtimefor
Figure 2 Singing sessions with families in the Royal Brompton
Hospital play room © Elam Forrester
15 Section 1: Programme Structure and Artistic Interventions15
preparation,evaluationandreflectionfactoredintothefee.Given thenatureoftheworkandtheunpredictabilityofinteractionswithpatients,thereisverylimitedtimeattheendofasessionforthemusicianstoevaluate,debriefandsharereflections,andthereisoftennosuitablequietspaceinwhichtodoso.Iftheprogrammeistocontinueevolvingandaimingforbestprofessionalpractice,theremaybearequirementtoformalisetheseelements.Thestatusofthefreelancecontractscouldbereviewedtobecomepart-timesalariedroles–particularlyfortheleadmusician,ifappropriate.Notwithstandingtheincreasedfundraisingchallengethiswouldentail,suchamovecouldconsolidatethestatusof VocalBeatsandenablefurtherdevelopmentof theprogrammeasanationalandinternationalrolemodel,byincorporatingresearchandintegrated practice.
Professional DevelopmentContinuingProfessionalDevelopment(CPD)isvaluedandencouragedatRoyalBrompton&HarefieldNHSFoundationTrust,andtheprojectteamandcoreteamofmusicianshavehadaccesstoarangeofopportunities.However,thecomplexityoftheworkmeansthatthereisacontinualimpetustodevelopknowledgeexchange,trainingandnetworks;thisisdiscussedfurtherinPart2ofthisreport.
InternaltotheVocalBeatsprogramme,therangeofexpertise,skillsandknowledgeintheteamgivesrisetoongoingopportunitiestolearnfromoneanother.ThecommitmentofphysiotherapistsandotherclinicianshasbeencrucialtotheimpactfuldevelopmentofVocalBeats.Thereiscurrentlyacademicresearchbeingconductedintothesynergiesbetweentheartsandthehealthcaresectors(Intersectoral action: the arts, health and wellbeing, Synergy between sectors: the arts as a tool to improve health and well-being, strengthening the link between health and the
arts,WorldHealthOrganisation,Sept2019)andit isupliftingtoobservethisbeingputintopracticewiththeinter-disciplinaryknowledgeexchangethattakesplacebetweenthecliniciansandthemusicians.Inparticular,physiotherapistCharlotteWellshasobservedthemusiciansatworkandcontributedtotheirtrainingandknowledgewiththeaimofdevelopingagreaterunderstandingoftheclinicalaspectsofrespiratoryconditions.TheSinging and Beatboxing condition information sheet peer-to-peerdocumentthatsheproduceddescribestheclinicalconditionsandtheirsymptomsindetail,andsuggestswaysthatsingingandbeatboxingtechniquescanimpactonpatientwelfare.
Asasalariedemployee,ProjectCo-ordinatorConniRosewarneisabletoaccesslocalKensingtonandChelseaCounciltrainingopportunities,evaluation
Section 1: Programme Structure and Artistic Interventions
External training programmes completed by various Vocal Beats musicians include:
• OPUSMusic(opusmusic.org)
• SnapeMaltings:MOTMusiciansworkinginchallengingsettings(snapemaltings.co.uk/music/residencies/mot)
• VocalProcess(vocalprocess.co.uk)
• LEAPTalentDevelopmentProgramme(serious.org.uk)
• PulseArts(pulsearts.co.uk)
Within Royal Brompton & Harefield NHS Foundation Trust the musicians have access to:
• Adesignatedandevaluatedinductionprogramme
• Sharedreflectionsessions
• Supervision
• OpportunitiesforsharinggoodpracticeandsectorknowledgewithphysiotherapistCharlotteWells
16 Section 1: Programme Structure and Artistic Interventions
andsocialmediatrainingforcharities,andstatutorytrainingwithinBrompton&HarefieldTrustincludingsafeguarding,palliativecare,equalityanddiversity,andhumanrights.ShewasalsosupportedtoattendanartsandhealthresearchintensiveprogrammeledbyDaisyFancourtatSnapeMaltingsearlierin2019.
Knowledgeexchangeandprofessionaldialogueareconsideredmandatoryinthespecialistareaofartsinhealthcare,whichisarelativelynewfieldparticularlyforparticipatoryartsprogrammesinhospitals.Thereisongoingresearchintothebenefitsandimpactofthework,anditsinterfacewitharangeofclinicalandcreativedisciplines.rb&hArtscontributestothisresearchandisamemberofvaluablespecialistandwiderartsnetworksincludingLondonArtsandHealthForum,NationalAllianceofMusiciansinHealthcare,CulturalandWellbeingAllianceandNHSNationalPerformanceAdvisoryGroup(NPAG).Notwithstandingthatrb&hArtsisasectorleader,thepossibilityfortheverysmallteamtoattendmeetingsandconferencescanbelimited,owingto capacityaswellasaccesstofunding.
Musicians in Healthcare Mentoring ProgrammeTheMusiciansinHealthcareMentoringProgrammewaslaunchedin2018andisdeliveredbyrb&hArtsinpartnershipwithSoundConnectionsandsupportedbyYouthMusic.Therewerefiveearly-careermusiciansontheprogramme2018/19,andasecondcohorthasbeenselectedfromJanuary2020.AsimilarinnovativemusicmentoringprojectwasrecentlycompletedatAlderHeyChildren’sNHSFoundationTrustincollaborationwithLiveMusicNow https://alderhey.nhs.uk/services/arts-for-health,alsofundedbyYouthMusic.
Theobjectivesforrb&hArtsaretoofferthemusiciansprofessionaldevelopmentopportunitiesbygivingtheminsightsintoclinicalsettingswith
thebenefitsofshadowingand1-to-1mentoring.SoundConnectionsisinvolvedwiththeinductionprocessandoffersindividualdevelopmentneedsanalysis(DNA)toeachmenteeattheend oftheprogramme,helpingtoidentifyfurtherprofessional objectives.
Theextractsbelowaretakenfrominterviewsandreflectiveessays,ofwhichthelatterarearequirementoftheprogramme.Thesequotesillustratethequalityoftherecruitmentandtheinsightsthatthementeesgainedfrombeingimmersedintherb&hArtsenvironment.
Everyone is engaged with the same aims on the wards. You learn to create a space and build your sensitivity to situations. I appreciate music a lot more now. Nicola Tagoe, mentee
NicolahasundertakentrainingwithPulseArts,andthismentorshiphasinspiredhertoexpandherportfoliowithworkinEarlyYearssettings.ShehasrecentlybeensuccessfulinreceivingaDeveloping your Creative PracticeArtsCouncilEnglandaward.
17 Section 1: Programme Structure and Artistic Interventions
Heather [McClelland] had so many different techniques that she used to work with to keep the young people engaged and not feeling embarrassed; she was always encouraging and let them make the final decisions. She also checked in with them constantly to make sure that they were ok with what was happening. After reflecting on Heather’s practice, I identified several points that will be really important in my own practice:
• Identifying the end goal and working out with small steps what we can do to get there
• Believing in yourself and your ability, in order to hold the space so that you can check everyone understands and that whatever the outcome that is ok
• It’s ok to make mistakes; learn from them and carry on
• Being confident enough so that they trust you and go with what you are trying to do
Sasha Mattock, mentee, extract from reflective essay
Over the course of the programme my confidence increased as I became more used to the ward. And it was incredibly rewarding work. But it calls for a high degree of resilience. I was extremely impressed with the musicians’ ability to enable musical sessions that delivered
positive experiences for all the patients. And again having the benefit of an experienced mentor to discuss the issues with was very helpful. This allowed us to work through the emotions that came up during the sessions and reflect on how the music would have benefited the patients. Sara Fawcett, mentee, extract from reflective essay
Youth VoiceThestrategyforthehighlydistinctiveVocalBeatsprogrammehasbeentocreateacurrentandcontemporaryofferingthatappealstoyoungpeople.Thereareseveralestablishedprogrammesforparticipatoryartsaimedatchildrenandyoungpeopleinhospitalthatsharetheseaims,andeachhasitsownidentitydependingoncircumstances,clinicalspecialismsandsettings.TwoexemplaryprogrammesinLondonareatGreatOrmondStreetHospital(https://www.gosh.nhs.uk/wards-and-departments/departments/gosh-arts)andBethlemandMaudsleyHospitalSchool(https://bethlem-maudsleyschool.org.uk),whereCityofLondonSinfonia(https://cityoflondonsinfonia.co.uk/wellbeing/wellbeing-projects)iscurrentlyundertakingathree-yearresidency.
TheintroductionofbeatboxingtotheVocalBeatsprogrammetwoyearsagohasbeenparticularlysuccessful,becauseaswellasbeingfunandentertaining,itprovidesphysicalexerciseforrespiratorypatients;itcanalsointerestboyswho mayinitiallybereluctanttosing.
18 Section 1: Programme Structure and Artistic Interventions
Manyoftheyoungpatientswhoneedtoreturnto RoyalBromptonHospitalonaregularbasisaregivenukulelestotakehomeandareencouragedto continuetheirmusicalactivityandlearning.Theyarealsogivenresourcesasappropriate,includingrecordingsoftheirfavouritesongsandworksheetswith‘beatboxinghomework’.
‘Mum don’t forget to pack my ukulele’Themotherofa14-year-oldpatientrelatedtheimportanceofherdaughterknowingthattheteamofmusicianswouldbewaitingtomakemusictogetheronherreturntohospital.
Patients are given choice – there is nothing fixed or rigid. Trust builds up and the patients absorb the experience from afar even when they’re not inpatients Stac Dowdeswell
Young people feel heard – it’s not ‘teachery’ though learning is taking place. It allows freedom – it’s the young person’s sessionConni Rosewarne
Figure 3 Bellatrix leading beatboxing sessions © Elam Forrester
19 Section 1: Programme Structure and Artistic Interventions
Musical ProgressionItisevidentfromobservingseveralsessionsonthewardsandtalkingtotheteamofmusiciansthatthepatients’musicalprogressionisapriority,eventhoughcontinuityisinevitablyfragmented.However,considerationcouldbegiventosettinguppilotnetworkssupportingmotivatedpatientstocreateindividualpathwaysorlearningplans,inordertosustaintheirmusicalactivitybetweenhospitalvisits,intheirownlocality.Withthepermissionofpatientsandtheirfamilies/carers,therecouldbeliaisonbetweendesignatedVocalBeatscoremusiciansandwithschoolorcollegemusicdepartmentsornon-formalnetworkstosupportmusicalprogression,similartospecialistcliniciansinhospitalsbeingincontactwithGPs.Giventheintroductionofsocialprescribingopportunitiestheremightbepossibilitiesforthisprovisiontobesourcedandfunded.TheinitiativewouldseemtimelygiventherecentlaunchoftheNationalAcademyofSocialPrescribingpartnershipwithArtsCouncilEnglandandNHSEngland(https://www.gov.uk/government/news/social-prescribing-new-national-academy-set-up).
Inmanycasesmusicalpotentialhasbeendiscovered,unleashedandnurtured,anditseemsvitaltomaintainanddevelopthispotentialforthebenefitofpatients’skills,wellbeing,creativityandself-esteem.ThereisperhapsaninevitableironyinthefactthatmanyyoungpatientsareonlyaccessingmusicprovisionwhentheyreturntoRoyalBromptonHospitalforregularclinicalstays.
TherecentintroductionoftheVocal Beats Youth Ambassador programmeforthoseaged17-25willenableyoungpeopletoaccessfurtherresourcesonlineandtocreateamusicalnetwork;thisisanimaginativepeer-to-peerstrandwithpatientsworkingalongsidetheteamofprofessionalmusiciansandafilm-makertoaddresstheisolationthattheymayexperiencegiventhatmanyareunabletomakemusictogetherinperson.
As the initiativetakesshapeitcouldbeaprioritytoextendmusicalnetworksandshareinspirationwithexternalpeergrouporganisationssuchastheaward-winningBeatbox AcademyatBatterseaArtsCentre(bac.org.uk).
rb&hArtsrecognisesthebenefitsofintroducingArtsAwardsaccreditationtotheprogramme.ThoughitwashopedthattheVocalBeatsambassadorscouldundertakethis,ithassofarnotbeenfeasiblegiventhelogisticsandintermittentcontactwiththeyoungpeopleinvolved.Thereisimpetustomoveforwardhowever,andtoexploreitforthefuture,asaccreditationcanprovideausefulstructureifimplementedsensitivelyinpartnershipwiththepatients.Inaddition,individuallearningplansasreferredtoearliercouldbeintroducedandcreatedjointlybypatientsandprofessionalmusicians.‘Individual’planscouldalsoincorporate‘buddy’plansforensembleworkandforrecordingcompositionsandperformancesonlineorinperson.
Giventhatmostpatientsaregiventheopportunitytoplaytheukuleleonthewards,somemaywishtoexploreaccreditationbytakinganexam;thereisnorequirementtoreadnotatedmusic(http://rgt.org/exams/ukulele-exams.php).
Figure 4 Vocal Beats Youth Ambassadors; Mia, Skye, Eleanor
and Bethinn © Alex Hyndman
20 Section 1: Programme Structure and Artistic Interventions
Considerationcouldbegivento:
• Developinga360°pilotpathwayschemeforpatientstocontinuetheirmusicalactivityintheirownlocalitybetweenhospitalstays
• ResearchinghowthenewNationalAcademyforSocialPrescribingcouldbenefittheVocalBeatsprogramme
• SupportingVocalBeatsAmbassadorsindevelopingwiderpeernetworks
• ResearchingarangeofaccreditationmodelsthatmayberelevanttoVocalBeatsparticipants
The Profile of Vocal BeatsTheVocalBeatsprogrammewithitsyouth-ledethoshasreceivedrecognitionintheformofseveralawardnominationsincluding:
• FinalistinSocietyofPublicHealthAwardsArtsinHealthcategory(www.rsph.org.uk)
• VocalBeatsYouthAmbassadorsProgrammewasshortlistedforYouthMusicSocialActionAwards(https://www.youthmusic.org.uk/awards)
• KarenTaylorrb&hArtsLeadwasawardedaRoyalBrompton&HarefieldHospitalsStaffChampionAwardinrecognitionofherworkontheVocalBeatsprogramme
HeatherMcClellandwasinvitedtojoinaSingingonPrescription‘creativethink-tank’atSnapeMaltingsrecently,alongsideleadingpractitioners,researchers,policy-makersandclinicians.Thisisavaluableopportunityforknowledgeexchangewithinabroad‘musicinhealthcare’forumandforraisingtheprofileofVocalBeats.Furthermore–notwithstandingtheconstraintsoftimeandfunding–theprogrammeisnowonthecuspoffurtherexcitinginitiativessoitmaybeanopportunemomenttosharegoodpracticemoreextensivelywithawiderrangeofstakeholders;thesecouldincludeprofessionalandamateurmusicensembleswithwhomthereisanartisticsynergy;commercialandcorporateorganisations;andarangeoftrustsandfoundationswhomaywishtobecomemorefamiliarwiththeprogramme.
21
Section 2: The Artists’ Perspective Gráinne Hope
OneofthekeyaimsofthissectionofthereportistoreviewtheartisticqualityoutcomesinVocalBeats.Thisinvolvedinterviewingtheartistsonthesubjectoftheirlivedexperienceasprofessionalmusiciansworkinginhealthcareandhowthiscorrelatestoand/orimpactstheirprofessionalroleoutsidethehealthcaresetting.
22 Section 2: The Artists’ Perspective
Severalthemesforconsiderationemergedfromthedatacollectedthroughthediscussionsandobservations,withrelatedsub-themes:
• TheProfessionalMusicianinHealthcare:
• Roleofamusicianinhospital/artisticoutcomes
• Competencies/appropriateskillset
• Challengesasanartistworkinginthesetting
• Relationshipsof:
• Musiciansandstaff
• Musiciansandpatients
• Themusiciansasateam
• ArtistSupport:
• Reflection
• Journaling
• ‘MusicinHealthcare’training
Definingorcreatingaframeworkformeasurementofqualityoutcomesintheartsisrecognisedasachallengingtask,andissomethingthathasalwaysbeenopentodebate.Nonetheless,thereseemstobeanunderstandingsharedbymanyartsorganisationsthatoutcomesarespecifictoeachprogrammeandcontext,andshouldbeunderpinnedbyhowtheworkengageswithitsaudience.
InhisSupporting Excellence in the ArtsreviewcommissionedbytheDepartmentofCulture,MediaandSport,BrianMcMasterwrote:
For something to be excellent it has to be relevant, and for it to be relevant it has to be continually reinterpreted and refined for and by its audience.Whenlookingatartisticoutcomesseveralimportantconsiderationscometomind,ofthe
musical,personalandprofessionalcompetenciesof themusiciansfacilitatingthemusicalengagement,whoarecentraltothesuccessand qualityofanyprogramme.
Professional Musicians in Healthcare and Their RoleThemusiciansengagedintheVocalBeatsprogrammeweredrawntotheroleformanydifferentreasons.SomebecameinvolvedbyrespondingtoanopencallbythehospitalforanArtistinResidence,anotherwasinvitedtocoveramaternitypost,andseveralofthemusicianshadbeenprofessionalcolleaguespriortostartingin this role.
Whenaskedwhatmotivationsdrewthemtothisrole,thetwomainreasonsthatemergedwere:aloveofmusicandworkingwithchildren.Onemusicianadded‘itmadesense’(therole).
Whenthediscussionturnedtowhatkeepsthemworkinginthisroleonemusiciancommented,
…it’s really fun and it’s like a real privilege. It is intense and it’s not for everyone, there are big challenges, but – it is also like, it does gives you a sense of purpose
Figure 5 Baby with kalimba © Elam Forrester
23 Section 2: The Artists’ Perspective
ItisworthnotingthattheprofessionalmusiciansfacilitatingtheVocalBeatsprogrammeareallhighlyskilledprofessionalsinger/songwritersandchampionbeatboxers,andtheyallhavealotofexperienceworkingwithmusicandchildrenineducationandcommunitycontextsthatpredatestheirinvolvementinVocalBeats.
Duringthefocusgrouptherewassomeinterestingdiscussionaroundtheadditionalskillsandcompetenciesthemusiciansfeltwerenecessaryforahospitalmusicianrole;theseincludedtheneedforflexibility,adaptability,communication,theabilitytothinkunderpressure,tobesensitivetoandgenerouswithlettingthemusicbepatient-led,andtheneedtobeemotionallyintelligent.
Theyagreedthatitcanbechallengingwhen,withsomepatientswhoyouseeregularlyandformrelationshipswith,somethinghappenstothem–thatitcanbehardto‘block it out’.
Inboththeinterviewsandthefocusgroup,theartistsengagedwithexploringtheirdifferentrolesasprofessionalmusiciansandasprofessionalmusiciansinhealthcare,andtheimpactthateachrolehasontheother.Onemusiciancommentedthattheamountofcollaborationandimprovisingrequiredinthehospitalsettingmeantthattheirlevelofmusicianshiphadgoneup,andtheyhadalsobecomemorevocallyfit.Anothermusicianobservedthattheyhavenowbecomemoreacutelyawareofsituationsoutsidethehospitalsetting,andarebetteratreadingaroom(audience)asadirectresultoftheirroleasamusicianinhospital.Anotherimpactsharedbythemusicianswasthattheyarenowmoreawareofwhatpeoplearegoingthroughandthatthissometimescomesthroughintheirsong-writing.
Onemusiciancommentedthatitisveryeasyforthemnottoholdthetworolesinequalregard,butthatitremainsnonethelessimportantforthemasfacilitatorstorememberthattheyare
alsoperformingartists:whiletherolescanfeedintoeachother,itisimportanttomakespaceforeach one.
Themusiciansrevealedanumberofpersonalandprofessionalchallengestheyfaceintheirrole,includinginfindingbalancebetweenbeinganartistandtheirpracticeinthehospital.Onemusiciansaidthattheyfeltthatbeinganartistinahospitalinvolvedareallyfinedance:peoplelovetohearthemperformandhearabouttheirprofessionalmusiclivesoutsidethatsetting.Anothermusiciansharedthatitcanalsobeachallengemusically,assomeonewillalwaysaskyoutoplaysomethingthatyoudonotknow,andallmusiciansacknowledgethatyoucanneverbepreparedforeverysituation.Therewasaconsensusaroundtheparticularchallengeforamusiciantokeepevolvingandaddingtotheirrepertoirewithworkthatisrelevanttotheyoungpatients.
Whenthemusicianswereaskedhowtheymeasurethesuccessofamusicalengagementonesaid,‘everyone is so different, a success for one person is so different to another person’;anothermusiciannotedtheimportanceof‘recognising this context is very specific’andalso‘what’s already there’.The samemusicianaddedacommentwhichillustratesthatprogressionandsuccesslookdifferentin‘in-the-moment’contexts:
We are very lucky that little tiny things that might not be considered like a successful session in an
Figure 6 Music-making app ThumbJam on iPad © Nik Read
24 Section 2: The Artists’ Perspective
education establishment, like someone smiling or a baby tapping their foot, that’s an incredibly successful session in a subtle wayThemusiciansnotedthatthetrainingtheyhadreceivedtoimprovetheirunderstandingofcysticfibrosisandthephysicalcomponentsofbreathing,alongsidewritingartsobservationshadhelpedthemtorecognisewhatasuccessmightlooklikein thiscontext.Onemusicianwentontosay,
You have to develop a language to understand that [observation]
RelationshipsTheVocalBeatsmusicianshavedevelopedstrongrelationshipswiththeplayteamonRoseWard.Thereisahandoverfromtheplayteambeforethemusiciansheadoutaroundtheward,andaplayspecialistsometimesaccompaniesthemifthereis a complexcase,tomakeintroductionsifneeded.
Duringobservationofmusiciansontheirmusicvisits,itwascleartheywereverycomfortablenavigatingthehospitalsettingandfindingopportunitiestostartamusicalengagementor conversationaboutinstrumentswithpatientsand families.
Onemusiciancommentedthattheyfeltthenursesrecognisethevalueofwhattheyaredoingandwouldsometimesaskthemusicianstocontinuewhilethenursescarryoutasmallprocedure.
Laterindiscussions,thepotentialtoconsiderimplementingafurtherpastoralsupportfordesignatedstaffhandoversinalladultwardswheretheprogrammetakesplace-butdoesnotbenefitfromthepresenceofthepaediatricplayteam-emerged.Itwasfeltthatidentifyinganindividualor teamwhowouldbeabletofullybriefthemusiciansoneachyoungpersonwouldenablethemusicianstobettertailorthesessiontomeetthe
patients’individualneeds.Thiswouldbeespeciallyvaluableinmorechallengingcircumstancesonadultwardsandwouldcertainlyhelpaidtheimpactof themusicalsession.
Oneinterestingtopicthatcameupduringthefocusgroupandinterviewsconcernedtheextentofinformationaboutapatientthatmusiciansneedtofacilitateasession.Theyagreedthatabalancewasneeded;onemusiciancommentedthattheywouldforgohavinganyknowledgeaboutapatient’sbackground,andwouldratherjustgotothatpatienttoofferthechoiceandopportunitytoengageornot engage.
Anotherexpandedfurtheronthis,talkingabouttheimportanceofofferingyoungpatientsthechoicetotakepartinamusicsession
I can offer them a choice, and I have learnt quite recently that that is a humongous part of why I think what we do is so important – because they don’t get to choose that many things [in hospital] …and for them to say yes …I love that you can say no to me as well, I want to offer you something you can say no to, but also you can say yes, and if you choose to participate then it’s a little bit of normality I think, and a little bit of escapism, and giving that to someone is just magic … it’s a real privilege to be able to do that, I feel very lucky. Whenonemusicianwasinvitedtosharewhatdrewthemtothisrole,theycommentedthat,‘I think as humans what we all crave is connection’.They went on:
For some reason beatboxing really does that. It is always being seen
25 Section 2: The Artists’ Perspective
as a party trick, as a novelty; it’s more than that, it’s an art form and it is a language and it transcends everything. It transcends culture, style, age, sex, it’s just expression. And anyone can do it … it doesn’t matter about whether you’re the best or not. It’s whatever sound you make, every sound is a good sound, it doesn’t matter: it can be a whistle, a click, a word, but every sound is a form of their expression... It gives everyone a blank slate to start onTheVocalBeatsprogrammewasbeingdeliveredbyanindividualmusicianwhenitfirstcommenced;ithasnowgrowntobeaprogrammethatsupportsmusicbeingdeliveredindividuallyandinpairs.Theparticipatingmusicians’previousprofessionalrelationshipsandfriendshipsthatexistedbeforeworkingwiththeVocalBeatsprogrammehavecertainlyhelpedthembecomea solidmusicalandsupportiveteam.Asonemusiciancommented,‘it’sajoytocollaboratewithotherexceptional musicians’.
Artist SupportArecentresearchreportbyvisualartistNicolaNaismithentitledArtists Practising Wellfocusesonsupportforartistsandrecognisestherolethattheartist,manager,funder,commissionerandpolicymakershaveinsupportingthewellbeingofartists,andalsolooksatthefactthatthiswellbeingisessentialforthemtobeabletoproduce quality work.
Allthemusiciansinterviewedacknowledgedandwereverygratefulforthesupporttheycurrentlyreceivefromrb&hArtsandtheopportunitiesforcontinuedtrainingandsupervisionthattheyare offered.
Themusiciansfeltthattheircurrentinvolvementinprogrammedocumentationhashelpedcreatemoreawarenessoftheirrole,andthattheartsobservationstheydohavehelpedthemtoobservemoredetailsofthemusic’simpactduringeveryvisit.Theyacknowledgedthatwhiletheevaluationprocessescouldattimesseemcomplicated,theywerealwaysevolving.Nonetheless,acommonunderstandingamongtheteamwouldbebeneficialtothewaytheyapproachthedocumentationandthepotentialinturntogatherdeeperandricher data.
Themusiciansrecognisedtheneedtoreflectindividuallyandalsowiththeirteampartner.Onemusiciannotedthat‘on your own it’s quite lonely, so good to reflect [as a team]’.
Journalingisamorerecentadditiontothemusicians’practiceintheVocalBeatsprogramme.Themusiciansacknowledgedthatithasbeenveryhelpfulasaformofreflectionandinsupportingtheirwritingofcasestudies,butalsohighlightedthatitcanbesomewhatcomplicatedtofigureouttheevaluationprocess.Theyfeltitwasimportantforthemtomoreclearlyunderstandwhattheyaredocumentingandthedifferentformsofdocumentation(e.g.forthepurposesofdata,feedbackortheirownreflections).
NoneoftheVocalBeatsmusicianshadanyspecific‘musicinhealthcare’trainingpriortostartingtherolewithVocalBeats,althoughtwohadobservedanothermusicianintheteambeforecommencing.OneofthemusicianshasundertakensometrainingwithOpusMusicsincetheybeganwithVocalBeatsandallreceivedahospitalinduction.
AlltheVocalBeatsmusicianshavetakenpartinCPDtrainingrelatingtorespiratorydiseasesandtheyconfirmedthishashelpedthemunderstandmoreofthephysicalandmedicalchallengesofpatientstheymeet,andhasalsohelpedtoinformthemusicactivitiesthattheyfacilitateduringmusicalengagements.
26 Section 3: Clinical Perspective
Section 3: Clinical PerspectiveCharlotte Wells
Thissectionbrieflyreviewsthepublishedliteraturetobetterunderstandhowmusic,singingandbeatboxingcouldbebeneficialforcardio-respiratoryhealth;itreviewsclinicians’experiencesofhospital-basedsingingprogrammes(Singing for Lung Health);andexploresthepotentialbenefitsofcollaborativesessionsbetweenVocalBeatsandalliedhealthcareprofessionalteams.
27
Why Analyse this Intervention from a Clinical Perspective?Fromaclinicalperspectivemusicprovisionisseenasanalternative‘intervention’whichactsasanadjuncttotheotherpharmacologicalandnon-pharmacologicaltreatments.Itaimstopositivelyimpactonachildoryoungperson’sexperienceduringtheirhospitalstayandtosupporttheeffortsoftheclinicalteam.Itisalsohopedthatthesesessionswitheachpatientwillhaveanimpactbeyondtheirstayandignitethepossibilityofexploringmusicandallitshealthandwellbeingbenefitsathomeandinthecommunity.ThisideaissupportedbyGoldenberg’s(2018)literaturereviewwhichlookedatthecurrentbodyofevidenceconcerningtheeffectofsinginglessonsforrespiratoryhealth,andwhichincludedallexperimentalresearchdesigns.Sheidentified17studiesthatinvolvesinginginterventionsinchronicobstructivepulmonarydisease(COPD),asthma,cysticfibrosis,Parkinson’s,cancerandquadriplegia.Goldberg’sfindingsidentifiedimprovementsinphysicalfunctioning,qualityoflife,mood,breathingcontrolandtrendstowardsimprovedrespiratoryfunctionandrespiratorymusclestrength,withreductionsinperceivedsenseofbreathlessness,fearandmentalpain.Thissuggeststhereisaneedtofurtherexplorethepotentialbenefitsofvocalmusic-makinginrespiratoryhealthcaresettings.
How Might the Intervention Work?Forchildrenandyoungpeoplewithcardio-respiratoryconditions,therespiratorymusclesplayanimportantroleinmaintaininglunghealth.Airwayclearance,breathingcontrol,respiratorymusclestrengththroughexerciseandbreathingpatterns:thesearecommonthemesinhealthmanagementforpeoplewithavarietyofheartandlungconditions.Thestrengthofthemusclesinvolvedinbreathingisimportantandcanaffectmanyoutcomesforchildrenstayingonthewards
at RoyalBrompton&HarefieldNHSFoundationTrust,including,forexample:
• howquicklychildrensuccessfullycomeoffventilatorsupportaftersurgery
• howeffectivelychildrencancleartheirchestofexcesssputum
• howablechildrenaretoexerciseeffectivelywithoutseverebreathlessness(Enright,2004;Reid,2008;Chang,2006;andWiddicombe,2006).
Studieshaveshownthatsingingrequiresregulationofairflowandencouragestheuseofagreaterlungcapacity(Collyer,2009,Sundberg,1987).Encouragingalargertidalvolumethroughbetterlowerthoracicbreathingmimicshowsomeairwayclearancetechniqueswithinphysiotherapyinterventionswork.Theactivecycleofbreathingtechniques(ACBT)developedbyPryorandWebberdescribehowthelargertidalvolumesattainedinthistechniquearethoughttohelprecruitoropenareasinthelungswheresputumhasblockedanairway,helpingtomobiliseandclearthesecretions.Goldenberg(2018)suggeststhattheshearingforcesandoscillatingpressuresgeneratedinthelungsduringsingingcouldhelpmobilisesecretions,
Figure 7 Active Cycle of Breathing Techniques (ACBT)
developed by Pryor and Webber
Section 3: Clinical Perspective
28 Section 3: Clinical Perspective
hydratetheairwaysurfaceliquidandreducetheviscoelasticpropertiesofthesputum,makingiteasiertoclear.Onthisbasis,wesuggestthatbothexerciseandsingingsessionscouldactinasimilarwayasanadjuncttoairwayclearanceforrespiratorypatients,mobilisingsecretionsandtherebymakingiteasiertoclearsputum.Benefitsof singingincludethatitdoesnotrequireanydevices,patientscandoitontheirown,andtheelementoffunandenjoymenthelpsreducetreatmentburden(Raskin,2009).
Bothphysiotherapytechniquesandsingingtechniquesfocusontheimportanceofposture,diaphragmaticbreathingandbreathcontrol.Althoughvarioustechniquesexist,theonemostcommonlyusedinbothphysiotherapyandsinginginvolvesdescentofthediaphragmoninspiration,leadingtothelateralmovementofthelowerribsina‘buckethandle’motionwhichtogetherpushtheabdominalwalloutwardsjustbelowthexiphisternum;followedbyeitherpassiverelaxationonexpirationinnormalrestingbreathing;or,duringairwayclearancesuchasAutogenicDrainage(AgostiniandKnowles,2007),ForcedExpiratoryTechniques(FETs)inACBTandinsingingsessions,thecontractionofabdominalmusclestocontrolan‘activeexpiration’thatpushestheabdominalviscerabackupagainsttherelaxingdiaphragm.Withinphysiotherapybreathingcontrolsessions,pursed-lipbreathingiscommonlytaughtasamethodthatcreatesresistancetotheexhalationinordertomaintainsomepositiveexpiratorypressure,therebyreducingthepossibilityofairwayclosure.Thiscanhelpbreathcontrolonactivityandexercise.Goldenberg(2018)suggeststhat,‘the lengthened airway, positive expiratory pressures and long sustained phrases required in singing can theoretically inhibit the collapse of airways’inasimilarwaytopursedlipbreathing.Bothcanhelpreducethesensationofbreathlessness,empowerpatientswiththeabilitytocontroltheirbreath
whilstmoving,andreducetheriskofover-breathingordisorderedbreathingpatterns.
Bothphysiotherapyandsingingsessionsencourageposturalrealignmenttoachievenormalspinalcurvature,engagementofcorestabilisingmusclesandpelvicfloor,aswellasrelaxationaroundtheneckandshoulders.Inthecontextofphysiotherapyinterventionsthisistoachievebetterairwayclearancetechniques,amoreeffectivecough,improvethebreathingpatternandreducestressincontinence;insinging,ontheotherhand,itisforthepurposesofbetterbreathcontroltoachievelongersustainedphrasesandbettercoordinationbetweenmuscles.Althoughthepurposesbehindtheuseoftheinterventioninphysiotherapyandsingingaredifferent,theoutcomeisthesame,andbothinterventionscanimprovepostureandstrengthencoremuscles,whichwillinthelongtermbenefitthepatientandreducetheirriskofinjury,long-termbackpain,andstressincontinencecausedbychroniccoughingduetothechild’srespiratoryconditionandrepeatedchestinfections.
Figure 8 Singing for Breathing warm up for vocal sessions using
fricatives and pursed-lip breathing exercises © Elam Forrester
29 Section 3: Clinical Perspective
Throughre-establishingdiaphragmaticbreathingandgoodposturalalignment,bothphysiotherapyandsinginginterventionsalsofocusonre-establishinga‘normal’or‘good’breathingpattern.Bythiswemeanchangingclavicularorapicalbreathingtodiaphragmaticbreathing,establishingagoodrhythmandflowtothebreathingpatterntoenabletheparticipanttoeitherexercisewithoutthediscomfortofexcessivebreathlessnessor,in singingpractice,toachievelongerphrasesandbetterbreathcontrol.ThestudiesinsingingforlunghealthbyLordetal.(2010)foundthatbetterbreathingpatternsandcontrolwereseenafterthesixweeksofsingingsessions.Thisishugelyimportantasdysfunctionalbreathinghasbeenfoundtobeasignificantcauseofbreathlessnesssymptoms,anxietyandmorbidityinpatientswithrespiratoryconditions(Veidaletal.,2017).Treatingdysfunctionalbreathingandre-establishinga‘normal’breathingpatterncanhelpreducerelianceonrelieverinhalers,andhospitaladmissionsaswellasimprovesymptomsforchildren(BarkerandEverard,2014).
Musicandsingingsessionsareoftenindividuallytailoredatthebedside,whichmakesmeasuringtheintervention,doseandoutcomefraughtwithchallenges.Whatisthe‘right’outcomethatwillcaptureachildoryoungperson’sexperience?Perkinsetal.(2018)encounteredthisissuewhentheywereunabletodemonstratethebeneficialimpactofasinglemusicsessiononpaininchildrenpost-surgery.Theyhighlightedtheneedtocreatea toolthatisabletoexploretheobservableimpactofmusiconchildren’semotionsandbehaviours.
Review of Clinicians’ Experiences of Singing Projects Within HealthcareOneoftheleadingprojectsatrb&hArtsandinthewidersectorisSinging for Breathing(orSinging for Lung Health),whichprovidesweeklysingingclassesforolderadultslivingwithCOPD.This
programmehasbeenenormouslyinfluentialinitsapproachandsuccesses,providinginspirationforcriticalthinkingandbuildingtheevidenceforVocalBeatsfromahealthperspective.ToreviewtheimpactSinging for Breathinghashadonbothparticipantsandclinicians,VictoriaHumeconductedaseriesofinterviewsonits10-yearanniversarybothwithpeoplewhohadparticipatedinaSinging for BreathinggroupandclinicianswhoworkedwithinRoyalBrompton&HarefieldNHSFoundationTrust.Thisworkledtothecompositionof‘TheSingingHospital’anditsperformanceattheRoyalCollegeofPhysiciansCatch Your Breath exhibition.Victoriahaskindlyallowedmetoreadandanalysethoseinterviewscriptsfromtheclinicians’experiencesofthissingingprojectwithinRoyalBromptonHospital;theseincludetheleadconsultantandaresearchphysiotherapistwhowereinvolvedintheprojectfromitsinception,anddoctorswhohaveworkedwithsingingprojectssinceithasbeenestablished.Overalltheprojectwasdescribedasahugelyjoyfulexperience,whichsuccessfullysupportedabilityandreducedthesocialisolationsooftenseenwithprogressiverespiratoryconditions.Themeswhichemergedfromacrossallthreeinterviewswere:
• Dynamicphysicalityofthesessions
• Practicalfocusonbreath
• Non-threateningtoamedicalparadigm
• Scientificevidence
Figure 9 Singing for Breathing perform 'The Singing Hospital' at
Royal College of Physicians, 2019 © Elam Forester
30 Section 3: Clinical Perspective
Dynamic Physicality of Singing SessionsEachpersoninterviewedcommentedearlyonthatthesurprisingthingthatwasmostnotableaboutaclass-basedsingingsessioninrespiratoryhealthwasthephysicalityofit;theactivityandenergylevelsweremuchhigherthanexpectedfromsucha class.
I saw that there was more to it than a sing-song quite quickly, just from the warm-ups that she was doing. Thewarm-upsandvocalexerciseswereactiveandapplicabletothephysiotherapyclassesforexercise-basedrehabilitation:
I was nearly immediately taking things on: how can I use this in PR [pulmonary rehabilitation]?
Practical Focus on BreathThroughouttheinterviewtranscriptstherewasconsiderationofhowbreathcontrolwasattendedtointhesessions,inawaythatwasverydifferentfromtraditionalbreathlessnessmanagement:
Well I think it’s a very deliberate physical activity. You have to hold yourself in a particular way, you have to control your breathing. And… you know, the output of that is very obvious: if you’re singing effectively or not.Thebenefitsandapplicationsofthisformofbreathingcontrolandfocusonbreathpatternwereconsideredbyboththephysiotherapistandconsultant.Theideathatitisimportanttoprepareyourbodytobreatheforsinging,justasforexercise,andthepotentialapplicationofthisconceptintothelivesoftheparticipantscouldbewhatenablesbetterfunction.
…there are likely to be many psychological benefits… but I think having an activity that is also physical in people who have a physical impairment, who are breathless and have detrained, become physically deconditioned because of their breathlessness. Singing for Breathingclasseswereseenasahugelypositivegroupactivitythatfocusedonabilityratherthanrespiratorydifficulties.
Breathlessness is something that people have in their heads. It’s a sensation. So it’s made up of the physical inputs that are coming back from the breathing, combined with what the person thinks their breathing is going to be like and what they’re expecting, so you start with people who expect to be breathless, they expect to be limited, they expect to be distressed, they’re fearful of breathing and breathlessness; so techniques that can overcome that, which may be something that you do as a different behaviour around breathlessness, may well be helpful.
Non-threatening to the Medical ParadigmThesuccessofanartsprogrammewithinahealthcareorhospitalsettingoftenrequiressupportfromleadorinfluentialconsultants,withwhomtheoverallresponsibilityforpatients’healthlies.Itisthereforeinescapablethattheremayneedtobesupportandendorsementfromconsultantsforanartsprojecttogainafootholdwithinthehospital
31 Section 3: Clinical Perspective
setting.Weareencouraged,then,thattheleadconsultantwhowasfundamentalintheSinging for Breathingresearchprojectscommentswithinthehospitalnotes:
It’s not challenging any kind of medical paradigm for me, it just seems like a perfectly normal, sensible thing, which you know is either useful or not for some or loads of people, and you know I think will take its place as a useful activity and something that we can recommend.Furthermore,anothercliniciandescribesitas;
…personalised medicine, you know? In the same way that we’re personalising things based upon people’s genetics and genomics, we should be personalising them on their human experience of culture and family – these are all just as much integral to creating personalised medicine…
Scientific EvidenceAllthreeinterviewsaddanoteofcautionaboutourcurrentknowledgelevelconcerningthetheoryandimpactofsinginginterventions.Theyalldescribethegoodlevelofqualitativeevidenceand experimentalevidence,butaswehavealreadyhighlighted,thereisaneedforrandomisedcontrolledtrialsbeforethistypeofinterventionwouldbewidelyacceptedasanadjuncttomedical care.
Thinking about it from a scientific point of view, there are going to be some things about it which are going to be true or not true so in terms of advocating for it, I think it’s important not to run ahead of the evidence.
Collaboration WorkCollaborativeworkingbetweensingingteachersandphysiotherapistshasbeenrecordedbeforeinliteratureandwithinthishospitaltrust.Lordetal.(2010and2012)documenteditintheirsingingstudyintervention;andbeginningwitha 30-minutesessionwithaseniorphysiotherapyonbreathingcontrol,thenaturalevolutionoftheVocalBeatsteamwassupportedbythepaediatricphysiotherapists.Havingahealthcareprofessionalwithinthewardandteamyouareworkingoncanbehelpfulforfacilitatingacceptanceofthesingersintothewardenvironment,tointegratepractices,tolearnanddevelopknowledgeofthehealth/diseaseconditionswithwhichthesingersareworkingandtohelpthemidentifywhatsuccessmightlooklikewithinasingingsession.Giventhatsingingandphysiotherapyareworkingtowardssomecommonaims,itisnaturalthatthisallianceoftenexists.
Figure 10 1-to-1 Vocal coaching session © Nik Read
32
Followingworkandsharedsessionsbetweenphysiotherapistandsingers,someformalteachingsessionswerearrangedforthewholeVocalBeatsteam.Fourhalf-daysessionswerearranged.Sessiononewasonthepathophysiology,medicalmanagement,andphysiotherapyaimsforeachcardio-respiratoryconditiontheymayencounteratRoyalBromptonandHarefield.Sessiontwoaddressednon-pharmacologicaltherapeuticaimsandtheorycommontophysiotherapyandsinginginterventionsforcardiorespiratoryhealth,Sessionthreefocusedontheoreticaldevelopmentofsinginginterventionsandsessionstailoredtoeachcardiorespiratorycondition.Sessionfourwasapracticalsessionsplitbetweenward-basedobservationoftailoringsessionsanddevelopingreflectivepractice.TheaimofthesessionswastoempowertheVocalBeatsteamtocreatepersonalisedsessionstakingintoconsiderationthechild’shealthconditionyetstillmaintaintheartisticelementoftheirwork.Developingthesingersunderstandingofbothhealthconditionsandthephysiologybehindhealthcareinterventionsenabledthemtobetterunderstandandrecognisewhatimprovementsparticipantsweremakingandhowsignificanttheycanbetotheiroverallhealth.Thistypeofeducation–whichwouldalwaysberecommendedforanysingingintervention,whetheritbeSinging for Lung Healthoralocalhospitalproject–iswhatsetstheprogrammeapartfromacommunitychoir:itgivesthesingerstheabilitytocreateatargetedtherapeuticinterventionbywayofanartisticoutlet.Ensuringregularreflectivepracticeisessentialforthesingerstolearnhowtoidentifywhat‘success’mightlooklikeintheclinicalareatheyareworkingin,tobetterunderstandtheirownpracticeandmaintaintheirownhealthandwellbeing.Reflectivepracticecanbedoneasanindividualbutbetterguidedwithasupervisororasateamandallowsmusicianstoprocesswhattheyhavenoticedwithinsessions,findingsignificanceinthingspossiblyoverlookedinthemoment.
It canallowincreasedawarenessofpatternsandresponsesleadingintimetoabetterunderstandingofbreathandsinging.
Goldenberg(2018)concludesherliteraturereviewbysaying:
The singing teacher who teaches a patient with respiratory disease should seek out information about the particular disease to understand the nuances of a student’s needs and, if possible, collaborate with the appropriate medical care team. Further studies of the impact singing has on respiratory disease and health are warranted.Itwasalsonotedinthe‘TheSingingHospital’interviews,inrelationtohowSinging for Breathing leadersneedappropriatetrainingpriortotakingon agroup:
We’re treating people’s voice, right? And there’s a whole profession – speech and language therapists – they should really be involved in this work as much as possible, because there’s a bit of evidence to suggest that if we improve dysphonia then we improve the amount of obstruction in their lungs. [But for] undiagnosed voice problems, singing incorrectly damages the voice [and] risks harm. Different leaders with different levels of expertise … need to pick out really, really technical aspects of delivery.
Section 3: Clinical Perspective
33 Conclusion
Conclusion with Recommendations for rb&hArts and Other ‘Music in Hospitals’ Programmes
34 Conclusion
AttheheartoftheVocalBeatsprogrammeliesa corebeliefinthevalueofsupporting,developingandenhancingthepatientexperiencethroughcreativemusic-makingandlearning.Thefollowingorganisationsformthefoundationwithoutwhichrb&hArtswouldnotbeabletodeliverthiswork:
• RoyalBrompton&HarefieldNHSFoundationTrust
• RoyalBrompton&HarefieldHospitalsCharity
• TheBromptonFountain
AbeliefintheefficacyoftheVocalBeatsprogrammeappearstopermeatetheethosofhospitallifeinthewardsateverylevel,engenderingknowledgeexchange,collaborationandsupport.ThisisevidencedbythequalityoftheworkwhichhasbeenrecognisedexternallyandparticularlyinthevitalfinancialsupportgivenbyYouthMusicandotherfunders.
Thoughthisreportreviewstheprogrammefromthreedistinctprofessionalperspectives,thereareoverlapsworthnoting.EachcontributorrecognisesthededicationofthemusiciansandthehighstandardstheyespouseineveryaspectoftheirworkatRoyalBrompton&HarefieldHospital.There isalsoaconsensusregardingtheimportanceofongoingdialoguebetweentheVocalBeatsteamandtheclinicalteam,intermsofsharingtheirspecialistknowledgeforthebenefitoftheyoung patients.
Themusiciansareconstantlydevelopingtheirpracticeinhospitalsettingsandasindividualleadingperformersandsongwriterswithhigh-profilecareers,anditisevidentthattheyconsiderbothaspectsaspriorities.Operationallythiscanbechallenging,notonlyintermsofdiaryclashes,butalsorisk-takingasartists,inpursuitoftheirgoalforpatient-ledmusicalinterventionsbasedoncollaboration,improvisation,and,fromthis,innovation.However,italsovalidatesthemand
bringsabroadstimulatingpresencetotheirworkon thewards.
In2015therewasoneMusicianinResidenceinRoseWard,andnowtherearefourmusicianswhooffersinging,beatboxingandukuleleonaweeklybasis,andalsoworkwithyoungadultsontheRoyalBromptonandHarefieldsites.Thissuccessstoryhasevolvedaccordingtoparticipantneedandbyseeingthepotentialtogrowtheprogrammeasitembedsinhospitallife,therebyenhancinganddeepeningthepatientexperience.Theadditionof1-to-1musicsessionsforyoungadultsin2018isanexampleoftheteam’scareandawarenessinaddressingthesocialisolationexperiencedbymanypatientswithcysticfibrosis.
AstheCreative PeoplechapterofEveryone can develop and express creativity throughout their life (Let’sCreate,ArtsCouncilEnglandStrategy2020-2030)states:
Children and young people talk passionately about the pleasure they get from creative activities (many of which they undertake in their own time, and often online) and how they use them to express themselves and develop their skills and confidence. They also talk about the important role that creative activities can play in helping them deal with anxiety, stress and social isolation.TheVocalBeatsprogrammeembracestheseaspirationsbyofferingpatientschoiceandtheopportunitytodeveloptheirmusic-making,buildingtheirskillstorealisetheirpotential.FormanypatientsthehospitalsettingatRoyalBromptonandHarefieldmaybetheonlyplacewheretheycandothis,andthereportrecommendsbuildingpartnershipsexternallytoextendtheopportunitiesandsharepractice.
35 Conclusion
Theareasofresearchandrobustevaluationinthisspecialistclinicalcontextarealsohighlightedinthereport.Itisrecommendedthattheseshouldbefurtherdevelopedinordertosharelearningacrossawiderhealthcareforumandtoprovideevidenceforsecuringfundinganddevelopingnewpartnershipsacrosssectors.OfparticularimportanceisaninvestigationintotheimpactandeffectofthemostcommonsingingorbeatboxingtechniquesusedwithintheVocalBeatsteam,sothatwemightbeabletobetterunderstandandunpicktheefficacyofthesetechniquesforchildrenwithheartandlungconditions.Analysisshouldfocusonsingingandbeatboxingtechniquesfromaphysiologicalandvocalcoachingperspective.Oncewehavedeepenedourknowledgeandevidenceforwhyandhowthesesingingtechniquesmightworkandthebenefitstheymayoffer,wecanthenmorewidelyrecommendtheiruseinavarietyofsettings.
rb&hArtsiswellplacedtobeattheforefrontofcurrentthinkingregardingpersonalisedmedicineandsocialprescribingintheworktheyundertakewithpatients,incollaborationwithclinicians.
Whilstrecognisingissuesregardingcapacityandfundraisingimperatives,itishopedthattheVocalBeatsprogrammewillgrowinprofileandgainfurtherrecognition;thoughthiswillinturnbenefitRoyalBrompton&HarefieldNHSFoundationTrust,itwillprimarilybenefittheyoungpatientswhoeveryoneagreesarethetoppriority.
Summary of Recommendations from the Three Sections of this Evaluation:
• Standardiseevaluationprocessesfortheteamofmusicianstogainacommonunderstandingandtoenablethegatheringofdeeperandricherdata.Themusicianswouldalsowelcomeclarificationofthetypesofdocumentationrequired.
• Furtherintegratethepracticesofthemusiciansandthehealthcareprofessionalstoidentifywhatsuccesswithinacreativemusicsessionmightlooklike.
• Amendthestatusofthefreelancemusicians’contractstopart-timesalariedroles,particularlyfortheleadmusician–ifappropriate,andsubjecttofunding.
• Continuetoexpandmusicians’knowledgebyattendingCPDopportunities,namelyworkshops,conferencesand/orexchangeprogrammesorcollaborationswithotherleadingprogrammesnationallyandinternationally.
• WithreferencetotheMusiciansinHealthcareMentoringProgramme:
• Developastandardisedapproachtomentor-menteerelationships
• Considerwhetherthementorswouldbenefitfromtailoredmentorshiptraining
• Identifyandclarifytheroleofthementeesduringsessions
• Facilitatetheobservationandreviewofmenteesinsomecapacity,creatingandleadinganinterventionwhereappropriate
• Invitesomeofthe‘alumni’menteesbacktoworkinsessionswiththeVocalBeatsmusicianswiththeaim
Figure 11 Participant playing the kalimba © Nik Read
36 Conclusion
ofbecomingdeputymusiciansinthefuture
• Considertheintroductionofanapprenticescheme
• Createanonlineforumorfurthermeetingopportunitiesformenteesduringthecourseoftheprogramme
• Developa360°pilotpathwayschemeforpatientstocontinuemusicalactivityintheirownlocalitybetweenhospitalstays.
• Considertheintroductionof‘individual’learningplansthatalsoincorporate‘buddy’plansforensembleworkandcompositiononlineorinperson.
• ResearchhowthenewNationalAcademyforSocialPrescribingcouldbenefittheVocalBeatsprogramme.
• SupportVocalBeatsAmbassadorsindevelopingwiderpeernetworksandorganisations.
• ResearcharangeofaccreditationmodelsthatmayberelevanttoVocalBeatsparticipants.
• Shareevidenceandgoodpracticemoreextensivelywithawiderrangeofstakeholders;thesecouldincludeprofessionalandamateurmusicensembleswithwhomthereisanartisticsynergy;commercialandcorporateorganisations;andarangeoftrustsandfoundationswhomaywishtobecomemorefamiliarwiththeprogramme.
• Furtherexplorethepotentialbenefitsofvocalmusic-makinginrespiratoryhealthcaresettingsthroughformalisedresearch.
• Seekopportunitiesforfurtherclinicalstaffbuy-in;bypresentingtophysiotherapyteams,forexample.
• Createatooltoexploretheobservableimpactofmusiconchildren’semotionsandbehaviours.
• Embedstructuredreflectivepracticeintothemusician’sworktodevelopexperientiallearningandself-supervision.
37 Conclusion
Additional Information ResourcesCysticFibrosisTrust(https://www.cysticfibrosis.org.uk/what-is-cystic-fibrosis)
StandardsofCareandGoodClinicalPracticeforthePhysiotherapyManagementofCysticFibrosis(https://www.cysticfibrosis.org.uk/the-work-we-do/resources-for-cf-professionals/consensus-documents)BritishLungFoundation(https://www.blf.org.uk)
AsthmaUK(https://www.asthma.org.uk)
PrimaryCiliaryDyskinesia(https://www.blf.org.uk/support-for-you/primary-ciliary-dyskinesia-pcd)
BritishHeartFoundation(https://www.bhf.org.uk)
Further ReadingIrons,J.Y.,Petocz,P.,Kenny,D.T.,Chang,A.B.(2019)‘Singingasanadjuncttherapyforchildrenandadultswithcysticfibrosis’,Cochrane Database of Systematic Reviews,issue7.Availablefrom:DOI:10.1002/14651858.CD008036.pub5.
Irons,J.Y.,Kenny,D.T.,Chang,A.B.(2010)‘Singingforchildrenandadultswithbronchiectasis’,Cochrane Database of Systematic Reviews,issue2.Availablefrom:DOI:10.1002/14651858.CD007729.pub2.
Lewis,A.,Cave,P.,Stem,M.,Welch,C.,Taylor,K.,Russell,J.,Doyle,A.M.,Russell,A-M.,McKee,H.,Clift,S.,Bott,J.andHopkinson,N.(2016)‘Singingforlunghealth–asystematicreviewoftheliteratureandconsensusstatement’,npj Primary Care Respiratory Medicine,issue26.Availablefrom:DOI:10.1038/npjpcrm.2016.80
38
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Lord,V.M.,Cave,P.,Hume,V.J.,etal.(2010)‘Singingteachingasatherapyforchronicrespiratorydisease–arandomisedcontrolledtrialandqualitativeevaluation’,BMC Pulmonary Medicine,10.Availablefrom:DOI:10.1186/1471-2466-10-41.
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41 ACKNOWLEDGEMENTS
ACKNOWLEDGEMENTS
42 ACKNOWLEDGEMENTS
AlderHeyChildren’sNHSFoundationTrust(www.alderhey.nhs.uk/services/arts-for-health)
ArtsCouncilEngland(www.artscouncil.org.uk)
BatterseaArtsCentre(www.bac.org.uk)
BBCChildreninNeed(www.bbcchildreninneed.co.uk)
BethlemandMaudsleyHospitalSchool(www.bethlem-maudsleyschool.org.uk)
TheBromptonFountain(www.thebromptonfountain.org.uk)
CarolineMoore,ParticipatoryArtsManager,GOSHArts
CityofLondonSinfonia(www.cityoflondonsinfonia.co.uk/wellbeing/wellbeing-projects)
Culture,HealthandWellbeingAlliance(www.culturehealthandwellbeing.org.uk)
Foulis,RowanandFirTreeWards
GOSHArts(www.gosh.nhs.uk/wards-and-departments/departments/gosh-arts)
InstituteofPsychiatry,PsychologyandNeuroscience(IoPPN–www.kcl.ac.uk/ioppn)
JenniferRaven,DeputyDirectorSoundConnections(www.sound-connections.org.uk)
LEAPTalentDevelopmentProgramme(www.serious.org.uk)
LiveMusicNow(https://www.livemusicnow.org.uk)
LondonArtsandHealthForum(http://www.lahf.org.uk)
MusiciansinHealthcareMentoringProgrammeParticipants:NicolaTagoe,SaraFawcett,SashaMattock,LilaBhattacherjee,andAidenMaier
NationalAllianceofMusiciansinHealthcare(http://www.namih.org)
NHSNationalPerformanceAdvisoryGroup(NPAG–www.npag.org.uk)
OPUSMusic(https://opusmusic.org)
Parentsandcarersofpatients
PatientsofRose,Foulis,RowanandFirTreeWards
PulseArts(www.pulsearts.co.uk)
RoseWardclinicalstaffincludingwardsistersandPlayServices
RoyalBrompton&HarefieldHospitalsCharity(www.rbhcharity.org)
RoyalBrompton&HarefieldNHSFoundationTrust(www.rbht.nhs.uk)
SnapeMaltings:MOTMusiciansworkinginchallengingsettings(www.snapemaltings.co.uk/music/residencies/mot)
SocietyofPublicHealthAwardsArtsinHealthcategory(www.rsph.org.uk)
TheRoyalMarsdenCancerCharity (www.royalmarsden.org)
TheRoyalMarsdenNHSFoundationTrust (www.royalmarsden.nhs.uk)
Theteamatrb&hArts:KarenTaylor,ConniRosewarne,KarenJanody
TheVocalBeatsMusicians:HeatherMcClelland,StacDowdeswell,Bellatrix,MCZani
UkuleleKidsClubUK(https://uk.theukc.org)
VictoriaHumewhoverykindlygrantedususeofherinterviewtranscriptsfromresearchfor‘TheSingingHospital’.
VocalProcess(www.vocalprocess.co.uk)
YouthMusic(www.youthmusic.org.uk)
YouthMusicSocialActionAwardsponsoredbyHalLeonard(https://www.youthmusic.org.uk/awards)
43
APPENDIX: Description of Conditions
44 APPENDIX
ListedbelowaredetailsofthemainheartandlungconditionsthatthechildrenandyoungadultswhoareinpatientsatRoyalBrompton&HarefieldHospitalsmayhave.ThesedetailsareprovidedtogivecontexttotheVocalBeatsworkandthepeopletheymaybeworkingwith.
Cystic FibrosisCysticfibrosis(CF)isageneticallyinheritedlife-limitingconditionthataffectsallthemajororgansofthebody,suchasthelungs,pancreas,bowel,liverandkidneys.Inbrief,itoccursbecauseanalteredcysticfibrosistransmembraneregulator(CFTR)genecausesthecellsinthebodytohaveanimbalanceofsodiumandpotassium,whichleadstomembranesbecomingdehydratedandsticky.Thickmucusbuildsupeverywhereinthebodybutparticularlyinthelungsanddigestivesystem:theairwaysproducethickmucuswhichishardtoclearandmakespeoplewithCFmoresusceptibletolunginfections.Repeatedinfectionsintheairwaysleadtoirreversibledamage(Ironsetal.,2019).ThemanagementofCFcaninvolveacomplexdailytreatmentprogrammethatusuallyincludesairwayclearancetechniques,physicalexercise,pancreaticenzymesandothermedications,aswellashospitaladmissions.Suchanintensivetreatmentregimenmayhaveanegativepsychosocialimpactonchildrenandadolescents(Glasscoe,2008),particularlyadolescents(D’Auria,2000).PreviousstudieshavefoundthatindividualswithCFmayhavepoorqualityoflife(QoL)(Quittner,2008).
BronchiectasisBronchiectasisisdiagnosedthroughidentificationof‘irreversibledilationofperipheralairways’onaCTscan.Thesedamagedairwayscauseover-productionofmucus,however,thesamedamagemeanstheairwaysareunabletoclearthesesecretions,whichleadstoanongoingcycleofinfectionandfurtherlungdamage.Theseexacerbationsfrequentlyrequirehospitalisation
fortreatment.Themanagementofbronchiectasisinvolvesmaintainingrespiratoryhealth,clearingtheairwaysandphysicalexercisetomaintainphysicalfunction.
AsthmaAsthmaaffectstheairwaysinthelungsofchildren,youngpeopleandadults,andcanchangeoverthecourseofalifetime.Typicalsymptomsofasthmamayincludebreathlessness,difficultybreathing,tightairways,coughingandwheezing;thesesymptomscanbepersistentorintermittent,andmaychangeasachildgrowsup(GINA,2018).Theaimofasthmamanagementistominimisesymptoms,exacerbationsandhospitaladmissions;tofindtheminimumdoseofeffectivemedicationtoavoidadverseeffects;tomaintain‘normal’pulmonaryfunction;andtoenableachildtoparticipatefullyinphysicalactivity(GINA,2018).Asthmamanagementusesinhalersandmedicationstotreatinflammationandinfectionintheairways,aswellasnon-pharmacologicalinterventionswhichmayincludepsychologytohelpwithanxietyandadherencetomedications,andphysiotherapytohelpwithexercise,airwayclearance,symptomdifferentiation,breathcontrolandbreathingpatternretraining(Veidaletal.,2017).
Primary Ciliary DyskinesiaPrimaryciliarydyskinesia(PCD)isarareinheriteddiseasethataffectscilia,whicharetiny,hair-likestructuresthatlinetheairways.Ciliamoveinunisoninwave-likemotions,carryingmucustowardthemouthtobeswallowed,coughedorsneezedoutofthebody.Themucuscontainsinhaleddust,
45 APPENDIX
bacteria,andothersmallparticles.Iftheciliaarenotworkingwell,bacteriawillremainintheairways,whichcancausebreathingproblems,cyclesofinfection,andotherdisorders.PCDmainlyaffectsthesinuses,ears,andlungs.SomepeoplewhohavePCDhavebreathingproblemsfromthemomentofbirth.ThemanagementofPCDinvolvesairwayclearancetechniques,sinusrinsing,maintaininglunghealthandphysicalfitness.Treatmentofinfectionsfrequentlyrequireshospitalisation.
Post-Cardiothoracic SurgeryAwiderangeofcardiacandthoracicsurgeriesareperformedatRoyalBromptonHospital&HarefieldHospital.Theseincludemeasuresfromcorrectionofcongenitalmalformationoftheheart,tolungtransplants.Oncesurgeryiscompleted,recoverycantakefromaslittleas5daysuptoseveralmonthsbeforereturningtofullfunctionanddischargehome.Differentsurgeriesrequirevaryingincisionsites,whichcanmeanthechild’schestmay
havebeenopenedviathesternumorribs.Aftersurgerychildrenspendtimeontheintensivecareunitwhichcanbenoisyandfrighteningforthem;theyoftenneedtohaveintravenousmedication,chestdrainsandlinesinandontheirbodies.Theymayneedtoundergopainfulprocedures;althoughmovingaroundaftersurgerymayalsobepainful,itisanimportantstepforensuringthechild’srecovery.Afteralungtransplanttimeinisolationmayalsoberequireddependingoneachpatient’simmunesystemandtheirbody’sacceptanceoftheneworgan.Nervescanbecutorbruisedduringsurgery,andthiscanalterthepatients’abilityto‘feel’theirbreathing.Oncerecoveredandmovedtohighdependencyunitsandthegeneralward,fewerlines,drips,drainsandmedicationareneededandthechildrenarefreertomoveandplay.Dependingonthesurgeryandincisionsite,childrenwillbegivenadviceonwhattheycanandcan’tdountilfullyhealedoverthenext6weeksto3monthsathome.
46
rb&hArts would like to give special thanks to Marion Friend MBE, Gráinne Hope and Charlotte Wells for all their work and support to create this brilliant report, along with Youth Music, without whom this would not be possible.