The addition of arts in medicine as a discipline on a clinical unit can positively affected both unit culture and patient care (Sonke et al, 2015). While a musician is not a clinician or a care provider, a musician can be considered a part of the interprofessional care team on an emergency or trauma care unit, as in other areas of a hospital.  Clinical staff, including doctors, nurses, and other clinical service providers, may call on a musician to help them address a patient’s needs, including stress reduction and general coping. Musicians must clearly understand the scope of practice appropriate to their role on the team, and maintain appropriate boundaries in the musical services they provide. In some instances where a patient may be displaying significant emotional needs, the musician may refer back to another clinical service provider.

Some general guidelines can assist musicians in acting effectively as a member of the interprofessional team:

• Musicians must be well oriented and acclimated to the clinical environment, including the unit’s culture, personnel, protocols, and safety measures.

• Musicians should work to develop relationships with both clinical and non-clinical staff members who may be engaged in patient care and unit management, and to familiarize these individuals with the practice of arts in medicine, specifically, music in emergency and trauma care. 
• Musicians should conduct themselves as professionals in the clinical environment, adhering to all hospital policies including dress codes and codes of professional conduct.

• Musicians should submit patient interaction information to other members of the care team in a manor appropriate to the workings of the unit and team communication structures.

The musician must also be aware of unit systems, such as those that protect the safety and privacy of patients and others in the environment of care and those that identify critical activity zones for staff. Musicians, like all members of the interprofessional care team should complete training on the following topics and procedures:

• HIPAA Patient Privacy laws and policies
• Patient Consent/Ethics
• Hand Washing Techniques
• Scrubbing and Gowning
• Blood Borne Pathogen Prevention and Exposure Control
• Location of Eyewash and Other Emergency Stations
• Infection Prevention and Universal Precautions
• Record Keeping Procedures (depending on the facility and program practices)

Musicians should always confer with unit staff regarding patients who should or should not be approached for a music interaction. Depending on the practice put in place for the program, the musician may confer with a unit’s charge nurse, unit clerk, attending physician or social worker.  These individuals may make recommendations regarding patients who should or should not be visited by the musician.

Generally, an inquiry such as, “Is there anything I need to know before I visit this patient?” will allow a care team member to share any essential information while adhering to patient privacy guidelines. However, in emergency and trauma care units, additional information regarding specific protocols or cautions posted on doorways may be needed.  A musician might also ask:

•  “I noticed there is a specific precaution on this patient’s door, are there any special protocols that I need to be aware of?”
• “I was referred to this patient but am unfamiliar with [observed caution], is it appropriate for me to interact with this person?”

A musician does not need to know a diagnosis or other medical details in order to work effectively with a patient, but the care team should have the opportunity to share any information that might be necessary in regard to patient safety and that might facilitate the most useful and enjoyable interaction. Particularly when caution signs are observed on a door, the musician should inquire about the appropriateness for music and any additional safety precautions that may be needed.

As noted previously, awareness of unit systems is essential for musicians, particularly those that identify critical activity zones for staff or staff members who are engaged in activities requiring a particularly high level of concentration. Music and music programs add to the complexity of the healthcare environment. While it can be a positive distraction, music has also been found to cause negative distraction for staff when it interferes with their work or concentration (Sonke et al, 2015). Musicians must insure that music being played for patients does not interfere with the work of team members. Communication on this issue is important and staff members should be encouraged by the musician to express any concerns related to music in the environment of care.

Many artists describe entering a patient room as one of the most challenging aspects of working as an artist in a healthcare environment. The following guidelines can assist musicians with making an effective and respectful entry into a patient room.

• The musician should begin to assess the situation in a patient room from outside the room.  With patient safety being the highest priority in a clinical setting, the musician should first observe any signs that may be posted on patient’s door or at the threshold of the unit.

• Musicians must take all the necessary precautions or measures that may be indicated, and must also insure that any musical instruments taken into the room adhere to infection control protocols.

• Normal hygiene practices, such as hand washing, must be adhered to.

• Most often, the patient or part of a patient’s room or partitioned space can be viewed from outside in an emergency or trauma unit. If the situation in the room or space seems overly tense or complicated, the musician may need to consult further with clinical staff to confirm a recommendation to see the patient at that time.  The musician should always err on the side of caution and respect for the patient’s privacy.

• When approaching the patient room, a musician should knock gently on the door (if there is one) and wait for a reply.  If no reply is heard, the musician may open the door slightly and gently announce him or herself to the patient.  It is important to wait for a response before entering the room. If no reply can be made, then the patient is unlikely to be able to consent to a music interaction. However, if no reply is heard, the musician may want to check again with clinical staff member, who may choose to make an introduction on behalf of the musician to facilitate the interaction. 

• If invited in, the musician may pull back the curtain just enough to see the patient without revealing them to others. 

Once in the patient’s space, the musician should introduce him/herself, including the programmatic affiliation (such as with the Arts in Medicine program) and let the patient know that they are there to offer music. 

If a patient turns down the offer for music, the musician should gracefully accept the decline and conclude the visit in the most appropriate way, which may include further informal conversation or an immediate exit. Good judgment in this stage of the interaction is essential. It is important for a musician to help patients to feel that they can say yes or no, and to help patients feel comfortable when they say no.

Once it is established that the patient would like to hear music, the musician should ask the patient what style of music they like or if they have any favorite artists or songs that they would like to hear. A musician can ask the patient’s name, but should avoid questions like “how are you?” or “how are you feeling today?” or other questions that could be perceived as clinical in nature.

The musician must also ask anyone else within hearing distance of the interaction if it would be all right for music to be played.  While sometimes difficult, this is an essential practice in any clinical environment, particularly an emergency or trauma unit where anxiety levels can be very high.  While preferential music may be very helpful to one patient, if it is increasing stress in any way for others in the environment, if should not be introduced.  The musician must understand that music can be both a positive distraction or a negative distraction in a clinical environment (Sonke et al, 2015), and take every measure to ensure that everyone exposed to music has consented independently and is likely to experience it as a positive distraction. If playing in a private room, the musician should be sure that the door is closed.  If playing in an open environment, the musician should set a volume level that insures that only those who have consented will be exposed to the music. 

A patient may provide the musician with a specific request, or may make a vague reference to a musical preference, suggesting that the musician “play anything”.  If the patient requests a specific song, the musician should take a moment to mentally review the lyrics of the song for anything that may be inappropriate for the moment, in that it may be too sad, explicit, or too “close to home” in a particular way.

In general, a musician might try to avoid songs that speak of death, loss, or other subject matter that could be overtly negative or emotionally disturbing. Typically, songs that are positive and uplifting lyrically, and that deliver a warm and soothing ambiance simultaneously are most likely to be appropriate.

The following songs and artists are generally accepted by a multitude of patients with great success, however the culture of the surrounding area in which the hospital lies will impact the efficacy of these suggestions. However, a patient may want to hear a song of that nature, and the musician would need to either express a concern to the patient or otherwise find a way to feel clear that the song is indeed appropriate for the moment.  This requires good judgment, which seasoned musicians in residence are able to develop.  Another option is for the musician to edit lyrics.  The musician should let the patient know that they play a slightly different version of the song, and ask it that is all right.    

If the musician is unable to fill a patient's request, she might offer other songs that are similar to the one requested. Taking time to suggest different songs may spur a patient’s memory of songs they like and spur a specific request.  If a specific song cannot be identified, the musician can try to help the patient identify a genre of music that they enjoy and play a selection from that genre.  In selecting a song, the musician might take into consideration the patient’s energy level, the general tenor in the room, or the patient’s general age range and the types of music that may have been a part of their life.  The musician should always ask the patient if the song they would like to suggest would be of interest, avoiding surprising a patient with a selection by starting to play it without permission. 

The phase one clinical trial conducted in 2014 in the Emergency and Trauma Care Center at the university of Florida yielded lists of the top 20 most requested and most performed (musician selected) songs, artists and musical genres over the 20-week study period. Click here to view the lists.

Musical preference is only one of several important components of performing music for patients in an emergency or trauma unit.  The musician must also carefully consider volume, tempo, tonal range, lyric content, and duration of performance and the visit.

After performing one song, the musician should wait for some sort of response from the patient. If the response is positive, the musician may ask of the patient would like to hear another song.  This is another moment when musician's judgment is needed. A seasoned musician in residence can often sense when a patient would like to conclude the interaction and when he or she might be receptive to more music.  

While performing, a musician must be actively observing the patient and sensing the environment.  If any discomfort is observed, the musician should conclude the song and either check in with the patient regarding their comfort with the music or find a way to graciously conclude the interaction and leave the room.  It is important to remember that most people want to be polite and hospitable, even in a hospital, and that the artist must make it easy for the patient to decline or conclude an interaction. 

In some cases, music can elicit an emotional response from the patient, which may lead to a narrative. In these instances, the artist should continue to hold the space and listen impartially as appropriate, but should not engage the patient in dialogue around emotional issues. Musicians trained to work in healthcare settings are adept at keeping conversation oriented to music as a form or art and enjoyment, without engaging in emotional processes. In some instances, the musician may need to conclude the session and refer the patient to a social worker or other clinical staff member. Good practice for a musician in residence involves a well thought our strategy to quickly and gracefully exit a patient room, should an interaction become inadvertently troublesome to the patient

Once the musical interaction is complete, the musician should thank the patient, exit the room, and complete any infection control procedures necessary before seeing other patients.  

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