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Complementary Therapies in Medicine (2009) 17, 190—195

available at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/ctim

Perceptions of group music therapy among elderly


nursing home residents in Taiwan
Shu-Ling Chen a,∗, Hui-Chuan Lin a, Sui-Whi Jane b

a
Department of Nursing, Hung Kuang University, Taiwan
b
Department of Nursing, Chang Gung Institute of Technology, Taiwan
Available online 29 April 2009

KEYWORDS Summary
Elderly; Objective: To explore the perceptions of group music therapy among elderly nursing home
Perceptions; residents in Taiwan.
Nursing home; Methods: Focus group methodology was used to explore the perceptions of elderly participants
Group music therapy; about their experience of group music therapy. Verbatim transcripts of audiotaped interviews
Focus groups were analysed by content analysis.
Results: In total, 3 focus groups were held with 17 wheelchair-bound elderly residents. Analysis
of participants’ perceptions of group music therapy revealed two major themes: (1) strength
derived from the group dynamic and (2) enhanced quality of life. The first theme included three
subthemes: (1) sense of energy, (2) distraction from suffering, and (3) confirmation as a person.
The second major theme included four subthemes: (1) variety added to life, (2) motivation to
exercise, (3) learning positive behaviour, and (4) greater life satisfaction.
Conclusion: Elderly, wheelchair-bound residents of a nursing home in Taiwan positively viewed
their experiences with our group music therapy programme, particularly its active component.
The findings of this study suggest that healthcare providers should consider integrating group
music therapy into their programmes for elderly nursing home residents and design the therapy
to add variety to their life, give them a sense of autonomy by having them choose their preferred
musical activities, and improve their cognitive function.
© 2009 Elsevier Ltd. All rights reserved.

Introduction tural changes have led to a shift in focus from the traditional
extended family to the nuclear family.2 In addition, couples
Aging populations are a global phenomenon, which is much have fewer children and more women are entering the labor
more pronounced in developed countries. In Taiwan, the force, resulting in fewer family caregivers available to pro-
population ≥ 65 years old grew from 1,490,804 (7.1%) in 1993 vide direct care for elderly family members.2 Furthermore,
to 2,287,029 people in 2006.1 In the past, Taiwanese adult 70% of Taiwanese elders suffer from one or more chronic ill-
children cared for their elderly parents, but social and cul- nesses, which are a major cause of disability.3 This increase
in the number of chronically ill and disabled elders has
increased the demand for institutionalised long-term elder
∗ Corresponding author. Tel.: +886 4 26318652x3005; care in Taiwan.4
fax: +886 4 26331198.
Elderly persons who are relocated to an institutional liv-
E-mail address: slchen@sunrise.hk.edu.tw (S.-L. Chen). ing environment may experience distress, social isolation,

0965-2299/$ — see front matter © 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctim.2009.03.002
Perceptions of group music therapy among elderly nursing home residents in Taiwan 191

sadness and profound hopelessness, resulting in an over- residents regarding their experience of group music ther-
all decline in physical and psychological functioning.5,6 To apy. Focus group methodology was chosen because it permits
improve the physical, psychosocial, cognitive, and spiritual nurse clinicians to explore a specific phenomenon in small
performance of elderly residents, healthcare providers at groups of older adults36 and to capture their dynamic
nursing homes recognise the importance of implementing interactions when they share commonality.37 Focus groups
activities such as music therapy.7—9 Most studies on the ther- also encourage a dynamic exchange among the partici-
apeutic effects of music therapy have been quantitative,7—16 pants, enabling them to react and build on the response
and only a few have been qualitative.17—19 Among the quali- of others.38,39
tative studies, only one examined the perspective of elderly
nursing home residents,17 but that study was published in
Chinese. Since many elderly Chinese people live in the west, Sample and setting
it is important for western clinicians to better understand
why music therapy works for elders and under what circum- Participants in the focus groups (N = 17) were recruited
stances, thus facilitating implementation of this programme by purposive sampling from a 350-bed nursing home in
in nursing home facilities. Therefore, the purpose of this Changhua City, central Taiwan. The facility was for elders
qualitative study was to examine the perceptions of group confined to a wheelchair. Eligible participants were (1)
music therapy among elderly residents of a nursing home in ≥age 65 years, (2) had participated in group music ther-
Taiwan. apy at least 3 months, (3) scored ≥24 on the Mini-Mental
State Exam40 to ensure they could express their feelings
and perceptions about participating in group music ther-
Characteristics and beliefs of elderly nursing home
apy, and (4) were willing to participate in a focus group
residents interview.
Among the 17 participants (11 females and 6 males) who
Elderly persons admitted to a nursing home are often participated in 3 focus groups, 4 participated in 2 focus
characterised by a deterioration in their physical and/or group sessions, with the remainder participating only in one.
mental health status. They have chronic health problems The participants’ mean age was 80.5 years (range = 70—90
accompanied by a gradually waning functional ability,20,21 years), and all had chronic illnesses. Nine participants
physical disabilities, and lack of family support.22 Institu- (52.9%) had not received any formal education, but were
tionalised elders report feelings of being abandoned, of able to speak and understand Mandarin. The remaining
feeling stressed by a lack of personal freedom and privacy, 47.1% had received primary education.
restrictions placed on their movements, and loss of control
over many aspects of their life.21,23—25 As a result, many
regard residential care homes as the ultimate ‘‘dumping Group music therapy
place,’’ where they will ‘‘idle till death.’’2626(p605) They
often consider their situation as ‘‘living in jail.’’2121(p913) The elderly participants received group music therapy for
Also, many institutionalised elders tend to isolate them- 1 h each week for 3 months, then once every 2 weeks
selves due to disease-related deterioration.27 from May 2004 to May 2005. The group music therapy
was adapted from previously described procedures,10,11 and
Therapeutic use of music included both active and passive musical activities. Each
session was subdivided into eight sections: initial phase,
Since the 1940s, music has been used as a non- warm up, dancing, group play with percussion instruments,
pharmacologic intervention to change behaviour, emotions, musical group play, listening to relaxing music, listening
and physiology28,29 in the areas of pain management, demen- to a musical performance by a guest performer, and the
tia, palliative care, and oncology.12,30 Music therapy has two concluding phase. For the initial phase, the facilitator (sec-
main branches: active and passive therapy.10,31 Active music ond author, HCL) greeted each participant by name and
therapy requires that participants play musical instruments welcomed them to the activity. During the warm up, the
or sing along with the therapist. In passive music ther- participants massaged each other’s hands or were assisted
apy, participants listen to live or recorded music.10,31 Music by volunteers. The elderly then moved their upper bodies in
provides sensory and intellectual stimulation that reduces time to the music, which varied gradually from a slow to a
stress in the elderly, increases their pain tolerance, relaxes fast rhythm. While they ‘‘danced,’’ they shook small bells
them, and distracts them from their pain.7,32 Music therapy and clicked castanets. Then the group played with percus-
improves older adults’ sleep quality33 ; decreases agitated sion instruments (e.g., drums, cymbals, or wood blocks),
behaviour,8,9,34 aggressive behaviour,35 and depression13 in followed by group-play without instruments (e.g., playing
patients with dementia. ball, blowing bubbles, or story telling), and listened to relax-
ing music. In the final activity, participants listened to an
invited guest sing or play an instrument. In the concluding
Methods phase, HLC expressed her appreciation to the participants
and shook hands with each one. After the music activities,
Design HCL also showed her respect for participants by asking about
their feelings, asking what songs they would prefer next
An exploratory qualitative design was used to gain a deeper time, or suggesting that they hum a song if they did not
understanding of the perceptions of elderly nursing home know the words.
192 S.-L. Chen et al.

Data collection ‘‘This group music activity makes me want to move because
the group has a powerful effect.’’ Similarly, participant (J)
Before data were collected, permission was obtained from said, ‘‘After I attended the group music activity, I felt happy
the head administrator at the nursing home since Taiwanese and energetic, especially with so many other people of my
nursing homes do not have institutional review boards. age group, as well as volunteers and nursing students join-
Elderly residents were fully informed about the study before ing in the activity.’’ Another participant (P) commented,
each focus group, assured of the confidentiality of their ‘‘Because there were many other elderly people that joined
data, and their oral consent was obtained. Permission was in this activity, I felt alive rather than sit around drowsing
requested to tape-record the session and take notes. all day long.’’
After 6 months of music therapy, focus groups were con-
ducted by SLC and HCL at the nursing home in the same Distraction from suffering
room used for the group music therapy. The focus groups While attending the group music programme, elderly resi-
were guided by three questions: (1) Can you please tell me dents gradually forgot their pains and discomforts, instead
about your feelings and thoughts when you attended this focusing on the music activity. For example, one participant
group music activity? (2) Which aspect of the group music (E) said, ‘‘Before this activity, I just waited for my 3 meals
activity influenced you the most? (3) What part of this group each day. I suffered in my mind about not being able to
music activity did you like best and why? go home. When attending this group, I concentrate on the
In total, three focus groups were held, each with six to activities and I forget how distressed I feel.’’ Another partic-
eight participants attending, and lasting for about 1 h. Focus ipant (H) related, ‘‘I have had Parkinson’s disease for a very
groups were held until no new information emerged from the long time, and I get tired from the tremors, they are very dis-
data analysis (data saturation).38 tressing. However, after attending this activity, I feel calm, I
forget the pain in my teeth, and I forget to be annoyed with
Data analysis my tremors.’’

Verbatim transcripts of the audiotaped interviews were Confirmation as a person


analysed by two stages of inductive content analysis.41 In the The participants felt taken seriously when greeted by name
first stage, verbatim transcripts of the three focus groups and welcomed to the activity. They felt respected as indi-
were independently coded by SLC and HCL. In the sec- viduals. One participant (I) explained, ‘‘At the beginning of
ond stage, the two researchers compared and discussed the activity, you [researcher] greeted me and shook my hand
their coding to reach consensus on coding, thus enhanc- after the activity. That made me feel respected and a very
ing dependability of the analysis. The dependability of the important member.’’
analysis was further enhanced by sharing the research find- This sense of being respected as a person and an indi-
ings with participants, who confirmed that the findings vidual gave them the feeling that participating in the group
accurately reflected their experiences.42 Finally, the trust- music activity increased their autonomy. They often felt a
worthiness of the data was ensured by using focus groups, lack of personal control in the nursing home, but when they
which typically have high face validity due to the credibility attended the music activity, they could choose their pre-
of participants’ comments.39,43 ferred percussion instrument and sing old, familiar songs.
For example, one participant (C) said, ‘‘When I joined this
activity, I could choose the drum and play it at full force,
Results it felt so great.’’ Similarly, another participant (G) said, ‘‘I
felt such freedom to shake the tambourine and to sing aloud
Analysis of participants’ comments about their experiences in this group music activity.’’
of group music therapy revealed two major themes: strength Some of the participants asked for more information
derived from the group dynamic, and enhanced quality of about group music therapy and the music. For example, one
life. These major themes and subthemes are described in participant (O) said, ‘‘I would like to know more about the
detail below. history or background of each song, because it would expand
our knowledge.’’
Strength derived from the group dynamic
Enhanced quality of life
This major theme refers to the positive aspects of engaging
in group musical activities. The music therapy programme This major theme describes the elderly nursing home res-
evoked a group dynamic that energised elders, helped dis- idents’ perception that participating in the group music
tract them from their psychological distress and physical activities positively impacted their quality of life in several
discomfort, and confirmed their self-worth. ways. The programme added variety to their lifestyle, moti-
vated them to exercise, taught them positive behaviours,
Sense of energy and enhanced their life satisfaction.
During music therapy, the participants met residents from
different units and participating nursing students. When Variety added to lifestyle
involved in playing instruments together, the participants The residents often felt that the nursing home lifestyle was
felt a sense of energy from the group dynamic, making them rigid, with an inflexible schedule for meals, bedtime, and
feel stronger and more alive. As one participant (A) said, rising. When they joined the group music therapy, they at
Perceptions of group music therapy among elderly nursing home residents in Taiwan 193

least experienced some variety in their life. As one partici- For example, participant (F) said,
pant (D) said, ‘‘The lifestyle in this nursing home is so routine
‘‘In the beginning I often wanted to die, because I did not
. . .eating, watching TV, and sleeping all day long. Every day
want to be a burden to my family. But, when I attended
is so boring. When I joined this activity, my life became
the group music activity I wanted to live my life as good
more interesting.’’ Similarly, another participant (N) said,
as I could, and exercise my body and take care of myself.
‘‘Before this activity, during the daytime, no one would talk
Thus, I changed my mind and decide to persevere with
to us or arrange any activity for us. I had no freedom to
my life.’’
act on my own in this nursing home and I could only sit on
the bed unless someone helped me into my wheelchair. My Another participant (O) said,
daily life is extremely boring and totally meaningless. The
‘‘I was afraid of my deteriorating health. My bones used
only thing I can do is waiting for each meal every day. Since
to ache and I did not know what to do about it, and
attending this group, my life has changed and I look forward
when I got up in the morning, both my hands and feet
to it all week.’’
were so cold. But now, after joining this activity, I know
The elderly participants felt involved, they enjoyed the
how to make my body warm, and the music activities
group music therapy, and it left them with the memory of
make me feel cheerful and relaxed, and now I have more
the musical rhythm, which afterwards stimulated them to
confidence to face the future and live.’’
exercise in the nursing home. For example, participant (L)
said, ‘‘Before, I waited for meal times and bed time each
day. Now when I get up in the morning, I have music in my Discussion
heart and begin to exercise by myself [taps his right hand
with the left hand].’’ This study found that 6 months after elderly residents of
a nursing home in Taiwan participated in a programme
Motivation to exercise of group music therapy, they perceived that they derived
The participants perceived that their physical function had strength from the group dynamic and their quality of life was
improved since participating in the music activity. One par- enhanced. The findings suggest that such a programme could
ticipant (A) said, ‘‘I have more strength in my hands and feet be used in residential care homes to counter the beliefs of
than before. Now, I don’t depend on the bed handrail, and I elders that these homes are the ultimate ‘‘dumping place’’
can get up quickly from bed [shows how he gets up quickly]. where they ‘‘idle till death.’’26
I am quite happy to learn many skills and I feel motivated The elderly participants perceived that these music
to exercise.’’ activities improved their physical function and made it eas-
Most participants expressed that since attending the ier for them to look after their own health. This finding is
music therapy, they actively used skills they had learned to consistent with Guzzetta’s assertion29 that music therapy
compensate for their impaired health. For example, par- encourages clients to become active participants in their
ticipant (M) said, ‘‘Through this activity, I learned how own health care. The move to a nursing home is often accom-
to massage myself and tap my body to avoid deteri- panied by major changes in an elderly person’s health.5,6 The
orating health.’’ Likewise, another participant (B) said, elderly participants described their mood as having changed
‘‘Sometimes, even when you [the researcher] didn’t come, from mostly depressed to happy and cheerful. These findings
I still had a musical rhythm in my heart and I exercised by are similar to those of other studies conducted in Taiwan
myself [demonstrates by lifting his paralyzed left hand with using music therapy to improve activity and psychological
his right hand].’’ status of elderly nursing home residents.15—17 Unlike those
studies, however, our study used a qualitative approach to
data collection and included both active and passive music
Learning positive behaviour activities. These methods allowed us to understand partici-
The majority of participants felt that the group music activ- pants’ perspectives and to engage them more actively in the
ities helped them to control their emotions better. For music therapy.
example, participant (G) said, ‘‘By watching and listen- Through group music therapy, the elderly participants
ing to others in this activity, I learned how to help and were gradually distracted from their suffering. This find-
care for others [in the nursing home], and I’m more open- ing is similar to a previous report7 that older people with
minded.’’ Another participant (K) observed, ‘‘I feel that osteoarthitis pain who listened to music had reduced stress
some of the people have better habits since they joined this levels and increased pain tolerance, simply by being dis-
activity. They follow group regulations and don’t grab the TV tracted from their pain. In addition, 10 of the 17 elderly
remote controller.’’ Similarly, participant (Q) said, ‘‘Before residents in our study perceived improvements in their
the music therapy activity, we had little respect for each depression, anxiety, and agitated behaviour. This finding
other. We always argued with each other. After attending is consistent with previous reports that music therapy
these music activities, we are more prepared to wait for decreased stress and irritable behaviour in the elderly.9,44
each other and show more respect to each other.’’ The elderly participants were also able to draw strength
from the group dynamic. The synergistic effects of the
Greater life satisfaction music and seeing other wheelchair-bound elders moving
Participants felt that their suffering was somewhat eased their upper limbs to the music and acting cheerfully moti-
and derived more satisfaction from life. Their mood changed vated everybody in the room. This dynamic helped them to
from negative (e.g., death wishes) to more positive, and learn positive behaviours. Moreover, the participants greatly
they felt encouraged to face their future. increased their interactions with other residents. This find-
194 S.-L. Chen et al.

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